Faculty Bibliography

BACKGROUND: The number of total shoulder arthroplasties has increased exponentially over the last ten years, creating a more prominent role for revision shoulder arthroplasty in the future. The main reasons for failure of shoulder arthroplasty can be classified as soft-tissue deficiencies, osseous deficiencies, component wear, or infection. We hypothesized that, despite appropriate surgical techniques, the outcome of revision total shoulder replacement can be predicted on the basis of the indication for the revision procedure. METHODS: We conducted a retrospective review of seventy-eight shoulders that had undergone revision shoulder arthroplasty. The shoulders were divided into two categories: (1) those with osseous or component-related problems and (2) those with soft-tissue deficiency. Category 1 consisted of four cohorts of shoulders: twenty-two treated with revision of the glenoid component, sixteen treated with conversion of a hemiarthroplasty to a total shoulder arthroplasty because of glenoid arthrosis, eight treated with revision of the humeral stem, and four treated for a periprosthetic fracture. Category 2 consisted of five cohorts of shoulders: ten treated with rotator cuff repair following total shoulder replacement, four with a failed tuberosity reconstruction, four with cuff tear arthropathy, five with instability, and five with infection. Patients were evaluated with the UCLA subjective outcome instrument, the L'Insalata shoulder questionnaire, and a subjective satisfaction scale (maximum score of 5 points). RESULTS: The average UCLA score was 21.4 points and the average L'Insalata score was 68.73 points for the seventy-eight shoulders that were analyzed. The average score on the subjective satisfaction questionnaire was 2.91 points. According to the UCLA scores, twenty-four revisions were considered to have had an excellent result; fifteen, a good result; twenty-four, a fair result; and fifteen, a poor result. The average scores for the category-1 shoulders were significantly better than those for the category-2 shoulders (p < 0.05). Of the different types of operations, revision or implantation of a glenoid component and open reduction and internal fixation of a periprosthetic fracture provided the best outcomes. Tuberosity reconstruction, hemiarthroplasty for treatment of cuff tear arthropathy, and revision due to infection had uniformly poor outcomes. CONCLUSIONS: In general, these results indicate that the outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure. Component revisions, excluding humeral head revision for salvage, provide the best results, whereas soft-tissue reconstructions can be expected to yield poorer results overall. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence

Patients who present with global capsular laxity and glenohumeral instability frequently can be treated successfully with shoulder girdle musculature strengthening exercises and activity modification. When such injury is caused by a paralytic shoulder, a rehabilitation program may not be a viable treatment option. Presented in this article are 3 patients with global capsular laxity and glenohumeral instability as a result of shoulder paralysis. We also describe an arthroscopic technique of thermal capsulorrhaphy. In our experience, arthroscopic thermal capsulorrhaphy used to treat global capsular laxity and glenohumeral instability resulting from a paralytic shoulder has decreased symptoms of shoulder instability and has significantly reduced shoulder pain

BACKGROUND: Chondral defects may lead to degradative changes in the surrounding cartilage, predisposing patients to developing osteoarthritis. PURPOSE: To quantify changes in the biomechanical and biochemical properties of the articular cartilage adjacent to chondral defects after experimental defect repair. STUDY DESIGN: Controlled laboratory study. METHODS: Specimens were harvested from tissue within (lesion), immediately adjacent to, and at a distance from (remote area) a full-thickness cartilage defect 8 months after cartilage repair with genetically modified chondrocytes expressing insulin-like growth factor-I or unmodified, control chondrocytes. Biomechanical properties, including instantaneous Young's and equilibrium aggregate moduli, were determined by confined compression testing. Biochemical properties, such as water and proteoglycan content, were also measured. RESULTS: The instantaneous Young's modulus, equilibrium modulus, and proteoglycan content increased, whereas water content decreased with increasing distance from the repaired lesion. The instantaneous Young's and equilibrium moduli of the adjacent articular cartilage were 80% and 50% that of remote area samples, respectively, whereas water content increased 0.9% and proteoglycan content was decreased by 35%. No significant changes in biomechanical and biochemical properties were found either in the lesion tissue or in adjacent cartilage with genetic modification of the chondrocytes. CONCLUSION: Articular cartilage adjacent to repaired chondral defects showed significant remodeling 8 months after chondral defect repair, regardless of whether genetically modified or unmodified cells were implanted. CLINICAL RELEVANCE: Changes in the biochemical and biomechanical properties of articular cartilage adjacent to repaired chondral defects may represent remodeling as part of an adaptive process or degeneration secondary to an altered distribution of joint forces. Quantification of these changes could provide important parameters for assessing progress after operative chondral defect repair

A ten-year retrospective review of extremity long bone gunshot fractures treated operatively at the Elmhurst City Hospital Center, New York, was performed to examine the operative outcomes with regard to immediate, intermediate, and delayed fixation. A total of 121 low-velocity gunshot fractures were evaluated in 107 patients. Cases were separated into three groups according to the actual timing of the internal fixation procedure. The results revealed a total deep infection rate of 2.6% (3/121) and a nonunion rate of 3.3% (4/121), with no significant differences among the three groups. Early internal fixation reduced comparative hospital stay length and overall costs for operative patients.