Orthopedics

Garofalo, R., F. Brody, A. Castagna, E. Ceccarelli and S. G. Krishnan (2016). “Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture.” Orthop Traumatol Surg Res 102(8): 989-994.

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BACKGROUND: Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture. HYPOTHESIS: RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury. DESIGN: Retrospective case series. MATERIAL AND METHODS: Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse. RESULTS: At final follow-up, average active elevation was 135 degrees (range 110 degrees -145 degrees ), abduction 122 degrees (range 60 degrees -160 degrees ), and external rotation 30 degrees (range 0 to 45 degrees ). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series. DISCUSSION/CONCLUSION: RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure.

Brodsky, J. W., J. M. Kane, S. Coleman, J. Bariteau and S. Tenenbaum (2016). “Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis.” Bone Joint J 98-b(10): 1369-1375.

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AIMS: The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis. PATIENTS AND METHODS: We prospectively studied 20 patients who underwent three-dimensional gait analysis before and after tibiotalar arthrodesis. Cadence, step length, walking velocity and total support time were assessed. Kinetic parameters, including the moment and power of the ankle in the sagittal plane and hip power were also recorded. RESULTS: Significant improvement was recorded across numerous parameters compared with pre-operative measurements. Temporal-spatial data demonstrated a significant increase in step length (p = 0.003) and velocity (p = < 0.001). Total support time decreased for the unaffected limb (p = 0.01). Kinematic results demonstrated that in the affected limb, total sagittal range of movement did not change significantly (p = 0.1259). However, the arc of movement had a near congruent shift with mean maximal dorsiflexion increasing from 5 degrees (-17 degrees to 16 degrees ) to 12 degrees (5 degrees to 18 degrees ) (p < 0.001) and mean maximal plantarflexion decreasing from 6.8 degrees (6 degrees to 21 degrees ) to 0.9 degrees (-9 degrees to 8 degrees ) (p = 0.003). Mean hip joint range of movement increased by 6 degrees (-7 degrees to 24 degrees ; p = 0.003). Kinetic results demonstrated no statistically significant change in ankle power (p = 0.1292). However, there was an increase in ankle moment (p = 0.04) and hip power (p = 0.01) in the surgically treated extremity. Sagittal plane range of movement was not reduced after tibiotalar fusion. CONCLUSION: Although following tibiotalar arthrodesis the gait demonstrated never matched the gait shown in unaffected ankles, compared with the pre-operative analysis there was improvement in numerous temporal-spatial, kinematic, and kinetic measures.

Garofalo, R., B. Flanagin, A. Castagna, V. Calvisi and S. G. Krishnan (2016). “Massive irreparable rotator cuff tear and associated deltoid tear. Does the reverse shoulder arthroplasty and deltoid repair be a possible option of treatment?” J Orthop Sci: 2016 Aug [Epub ahead of print].

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BACKGROUND AND PURPOSE: Rupture of the anterior and middle deltoid muscle associated with rotator cuff tear arthropathy (RCA) could result in a definitive loss of shoulder function. The purpose of this study was to evaluate clinical outcomes after a concomitant reverse shoulder arthroplasty (RSA) and deltoid repair under these circumstances. MATERIALS AND METHODS: Between 2006 and 2012, 18 consecutive patients with a mean age of 69.7 years, affected by massive irreparable rotator cuff tear and associated dehiscence or rupture of anterior and middle deltoid muscle underwent this operation through a modified anterosuperior approach. Four patients referred a previous shoulder surgery and deltoid tear was iatrogenic. The other 14 cases had an attritional deltoid tears. The average follow-up was 64 months (range 25-121 months). RESULTS: The mean active anterior elevation passed from a preoperative mean of 53 +/- 9.1 (range 45-70) to 132.7 +/- 11.6 degrees (85-155 degrees ), active external rotation passed from a preoperative mean value of 22.4 +/- 3.6 degrees (range 18-26) to an average of 33.7 +/- 4.7 degrees (range 30-40 degrees ). Mean Constant score increased from 42 +/- 6.1 (range 31-51) pre-operatively to 72.3 +/- 8.2 (range 57-82) post-operatively. At final review, deltoid contour subjectively was satisfactory to all patients with no palpable defects. CONCLUSION: RSA associated with a repair of deltoid tear could be a viable surgical option in cases of tear involving the anterior and middle deltoid associated with a RCA. Patient with a preoperative chronic axillary nerve neuropathy associated with a deltoid muscle tear should be cautioned about the possibility of lower functional outcomes.

Warren, A. M., A. L. Jones, M. Bennett, J. K. Solis, M. Reynolds, E. E. Rainey, G. Viere and M. L. Foreman (2016). “Prospective evaluation of posttraumatic stress disorder in injured patients with and without orthopaedic injury.” J Orthop Trauma 30(9): e305-311.

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OBJECTIVES: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. DESIGN: Prospective, longitudinal observational study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifty-nine participants admitted for at least 24 hours. MAIN OUTCOME MEASUREMENTS: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist-Civilian Version (PCL-C) measured PTS symptoms at 6 months. RESULTS: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. CONCLUSIONS: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury.

Pedowitz, D. I., J. M. Kane, G. M. Smith, H. L. Saffel, C. Comer and S. M. Raikin (2016). “Total ankle arthroplasty versus ankle arthrodesis: a comparative analysis of arc of movement and functional outcomes.” Bone Joint J 98-b(5): 634-640.

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AIMS: Few reports compare the contribution of the talonavicular articulation to overall range of movement in the sagittal plane after total ankle arthroplasty (TAA) and tibiotalar arthrodesis. The purpose of this study was to assess changes in ROM and functional outcomes following tibiotalar arthrodesis and TAA. PATIENTS AND METHODS: Patients who underwent isolated tibiotalar arthrodesis or TAA with greater than two-year follow-up were enrolled in the study. Overall arc of movement and talonavicular movement in the sagittal plane were assessed with weight-bearing lateral maximum dorsiflexion and plantarflexion radiographs. All patients completed Short Form-12 version 2.0 questionnaires, visual analogue scale for pain (VAS) scores, and the Foot and Ankle Ability Measure (FAAM). RESULTS: In all, 41 patients who underwent TAA and 27 patients who underwent tibiotalar arthrodesis were enrolled in the study. The mean total arc of movement was 34.2 degrees (17.0 degrees to 59.1 degrees ) with an average contribution from the talonavicular joint of 10.5 degrees (1.2 degrees to 28.8 degrees ) in the TAA cohort. The average total arc of movement was 24.3 degrees (6.9 degrees to 44.3 degrees ) with a mean contribution from the talonavicular joint of 22.8 degrees (5.6 degrees to 41.4 degrees ) in the arthrodesis cohort. A statistically significant difference was detected for both total sagittal plane movement (p = 0.00025), and for talonavicular motion (p < 0.0001). A statistically significant lower VAS score (p = 0.0096) and higher FAAM (p = 0.01, p = 0.019, respectively) was also detected in the TAA group. CONCLUSION: TAA preserves more anatomical movement, has better pain relief and better patient-perceived post-operative function compared with patients undergoing fusion. The relative increase of talonavicular movement in fusion patients may play a role in the outcomes compared with TAA and may predispose these patients to degenerative changes over time. TAKE HOME MESSAGE: TAA preserves more anatomic sagittal plane motion and provides greater pain relief and better patient-perceived outcomes compared with ankle arthrodesis.