Faculty Bibliography

INTRODUCTION: Shoulder arthroplasty provides excellent outcomes for most patients; however, a subset of these patients with a failed arthroplasty will require revision. Recently, the reverse total shoulder arthroplasty (rTSA) has been used in these difficult clinical situations. Therefore, we sought to examine our initial experience using rTSA as a treatment for failed shoulder arthroplasty. METHODS: During a 5-year period, 31 patients (mean age, 68.7 years) underwent rTSA for treatment of a failed shoulder arthroplasty and their presurgical and operative data were analyzed. Of the 31 patients, 28 were available for an average follow-up of 40.7 months. Their outcomes were assessed with American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA), and Simple Shoulder Test (SST) scores, and the visual analog scale (VAS) for pain. RESULTS: Compared with preoperative status, there were statistically significant improvements in all outcome measurements, including the ASES (24.0 to 66.2), UCLA (7.4 to 23.5), SST (1.5 to 7.6), and VAS (7.0 to 2.6). Active forward elevation improved from 44 degrees preoperatively to 108 degrees postoperatively (P < .001). Results were rated as good or excellent by 19 patients (67.9%), satisfactory by 4 (14.3%), and unsatisfactory by 5 (17.8%). Among the types of failed arthroplasty, patients with failed TSA noted the greatest improvement in their outcome, but this improvement was not statistically significant. CONCLUSIONS: The data suggest that patients can expect improved functional outcome and decreased pain after revision of previous arthroplasty to rTSA and that this procedure can provide a reliable salvage option for a challenging clinical problem.

We conducted a study to evaluate the outcomes and complications of open reduction and internal fixation (ORIF) of 2-, 3-, and 4-part proximal humerus fractures using a standard management protocol with locking plates. Of 72 patients with acute proximal humerus fractures managed with ORIF and locking plates, 63 were available at the minimum follow-up of 1 year and met the inclusion criteria. At each follow-up, radiographs were reviewed for healing, hardware failure, osteonecrosis, shoulder range of motion, and DASH (Disabilities of the Arm, Shoulder, and Hand) scores; any complications were recorded. Mean age was 62 years and mean follow-up was 19 months. There were 12 two-part fractures, 42 three-part fractures, and 9 four-part fractures. Thirteen patients had complications. Mean shoulder forward elevation was 135; patients with complications had a significantly lower mean forward elevation (P=.002). DASH scores were significantly lower in patients without complications than in those with complications (P=.01). Although excellent outcomes can be achieved when locking plates are used to manage proximal humerus fractures, complications are possible. Physicians must weigh the functional outcome data when considering management options for these types of injuries.

BACKGROUND: We sought to examine fracture settling and screw penetration after open reduction-internal fixation of 2-, 3-, and 4-part proximal humeral fractures and determine whether the use of calcium phosphate cement reduced these unwanted complications. METHODS: We performed a retrospective study of prospective data. Inclusion criteria included patient age of 18 years or older and an acute traumatic fracture of the proximal humerus that was treated with open reduction-internal fixation with a locked plate. Metaphyseal defects were treated with 1 of 3 strategies: no augmentation, augmentation with cancellous chips, or augmentation with calcium phosphate cement. Various radiographic measurements were made at each follow-up visit to assess for humeral head settling or collapse. Overall, 92 patients (81%) met the inclusion criteria and form the basis of this study. Augmentation type included 29 patients (32%) with cancellous chips, 27 (29%) with calcium phosphate cement, and 36 (39%) with no augmentation. RESULTS: There were no statistical differences among the groups with respect to patient age, sex, and fracture type. At the 3, 6, and 12-month follow-up visits, there was less humeral head settling with calcium phosphate cement compared with repair with no augmentation or with cancellous chips. Findings of joint penetration were significant among patients treated with plates and screws alone versus those augmented with calcium phosphate (P = .02) and for those augmented with cancellous chips versus those augmented with calcium phosphate (P = .009). CONCLUSION: Augmentation with calcium phosphate cement in the treatment of proximal humeral fractures with locked plates decreased fracture settling and significantly decreased intra-articular screw penetration.

BACKGROUND: Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair. MATERIALS AND METHODS: The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures. RESULTS: Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 +/- 14 years. The mean age in 2010 was 40 +/- 14 years (P < .0001). CONCLUSIONS: The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs.

Hip fracture is a potentially devastating condition for older adults. Hip fracture leads to pain and immobilization with complications ranging from delirium to functional loss and death. Although a mainstay of treatment is orthopedic repair, a multidisciplinary comanagement approach, including medical specialists and rehabilitation, may maximize patient recovery. Using the case of Mr W, an older man who sustained a fall and hip fracture, we present evidence-based components of care both in the hospital and outpatient settings. Preoperatively, clinicians should correct medical abnormalities and consider the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care. Perioperative care should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery. Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. Rehabilitation strategies should be tailored to patient needs; early mobilization followed by rehabilitation exercises in institutional, home, and group settings should be considered to maximize restoration of locomotive abilities. Attention to care transitions is necessary and treatment for osteoporosis should be considered. The road to recovery for hip fracture patients is long and most patients may not regain their prefracture functional status. Understanding and anticipating issues that may arise in the older patient with hip fracture, while delivering evidence-based care components, is necessary to maximize patient recovery.

The rotator cable is an extension of the coracohumeral ligament coursing along the undersurface of the supraspinatus and infraspinatus tendons. The rotator cable is thought to play a role in the biomechanical function of the intact and torn rotator cuff. It can be seen on all the imaging planes used for the conventional magnetic resonance imaging of the shoulder. Clinically, the integrity of the rotator cable can play a role in the treatment selection for patients with a rotator cuff tear.

BACKGROUND: Shoulder arthroplasty has become more prevalent, and patients undergoing shoulder arthroplasty are becoming more active. Recommendations for return to athletic activity have not recently been updated and do not consider the newest arthroplasty options. METHODS: A survey was distributed to 310 members of the American Shoulder and Elbow Surgeons, inquiring about allowed participation in 28 different athletic activities after 5 types of shoulder arthroplasty options (total shoulder arthroplasty, hemiarthroplasty, humeral resurfacing, total shoulder resurfacing, and reverse shoulder arthroplasty). RESULTS: The response rate to the survey was 30.3%, with 74.1% of respondents allowing some return to athletic activity after shoulder arthroplasty. The 28 athletic activities were grouped into 4 categories based on the load and possible impact to the shoulder. Only 51% of respondents allowed any participation in contact sports, whereas 90% allowed some participation in noncontact low-load sports. Return to sports after humeral resurfacing was highest, at 92.0% of the respondents, whereas the least percentage of surgeons allowed sports after reverse total shoulder arthroplasty, at 45.2%. CONCLUSION: The majority of surveyed surgeons allowed some return to sports after shoulder arthroplasty. Surgeons were more likely to recommend return to sports if the activities did not involve significant contact, risk of fall or collision, or application of high loads to the shoulder joint. Surgeons were also more likely to recommend return to sports if the arthroplasty did not involve the glenoid. CLINICAL RELEVANCE: The results of this survey may help surgeons counsel patients regarding return to specific athletic activities after various types of shoulder arthroplasty.