Arthroplasty for the Treatment of Fractures in the Older Patient, 2018
Proximal humerus fractures account for 4–5% of all adult fractures. Knowledge of the anatomy is v... more Proximal humerus fractures account for 4–5% of all adult fractures. Knowledge of the anatomy is vital in determining treatment and achieving optimal surgical outcome. A thorough history and physical exam is the foundation for correct treatment. Indications for shoulder arthroplasty for proximal humerus fractures in appropriate surgical candidates include three- and four-part fracture-dislocations, head-splitting fractures, impaction fractures of the humeral head with involvement of more than 50% of the articular surface, displaced anatomic neck fractures, and select three- and four-part proximal humerus in which there is a high risk of osteonecrosis or failure of internal fixation. Hemiarthroplasty is performed except in patients who are greater than 70 years old with poor tuberosity bone quality due to osteoporosis or comminution, preexisting chronic rotator cuff tear, or preexisting osteoarthritis of the glenohumeral joint. In such cases, reverse shoulder arthroplasty is preferred. Anatomic or conventional total shoulder arthroplasty is not utilized in acute proximal humerus fractures. Success with shoulder hemiarthroplasty or reverse shoulder arthroplasty for proximal humerus fractures is largely dependent on surgical technique. Goals of either surgery are proper restoration of prosthetic height, proper version, secure tuberosity attachment, and accurate soft tissue balancing of the rotator cuff.
Background: The purpose of this study was to compare postoperative opioid consumption following t... more Background: The purpose of this study was to compare postoperative opioid consumption following total shoulder arthroplasty, after: (A) a single-shot undiluted liposomal bupivacaine (LB; commercial name: Exparel) interscalene block, or (B) a Ropivacaine block (R), supplemented with continuous catheter infusion. Methods: This prospective, randomized study (NCT03739021) compared postoperative analgesic requirements in Morphine Milligram Equivalent (MME) during the first 24 h after discharge from the post-anesthesia care unit (PACU) in patients receiving total shoulder arthroplasty. Two similar groups of 30 patients each received equivalent general operative anesthesia. Preoperative interscalene block was performed with either 10mL of undiluted liposomal bupivacaine (LB) or ropivacaine (R) 0.5% plus continuous catheter infusion. Results: There were no differences between the two groups regarding age, gender, length of surgery, intraoperative narcotic usage, or length of hospital stay. ...
The reverse total shoulder arthroplasty has been well established as a successful treatment for r... more The reverse total shoulder arthroplasty has been well established as a successful treatment for rotator cuff arthropathy (RCA). The native glenoid is infrequently normal in the setting of a massive rotator cuff tear, and bone loss has been reported to be as high as 40% in some studies (Frankle et al., J Shoulder Elb Surg 18:874–85, 2009; Klein et al., J Bone Joint Surg Am 92:1144–54, 2010). With superior migration of the humeral head, there tends to be a vertical wear pattern that differentiates this pathology from primary osteoarthritis. Failure to recognize this wear pattern can lead to an error in surgical technique and may result in inadequate glenoid fixation or superior tilt of the glenosphere. These errors can lead to poor patient outcomes and early failure of the implant.
Issues of Rehabilitation, Orthopaedics, Neurophysiology and Sport Promotion – IRONS, 2021
Introduction and aim This paper reports on 5 key aspects to consider when planning a successful R... more Introduction and aim This paper reports on 5 key aspects to consider when planning a successful RSA procedure, including patient selection, glenosphere positioning, glenoid fixation, humeral fixation, and soft tissue management/tensioning. Material, methods, results, and discussion Key in patient selection for RSA is understanding the relationship between indications, outcomes, patient mental state, and their expectations. When placing a glenosphere, prioritize sound principles of shoulder kinematics but always consider bone preservation and ease of placement. Glenoid fixation must take advantage of structural features of individual implant designs while factoring in specific-bone morphology/morphometry to optimize the resultant glenohumeral loading. For the stem, fixation prioritizes press-fit where bone quality and quantity permit. Always aim to achieve anatomical pivot point restoration with planning for stem position and avoid distalization that may lead to nerve injury and scap...
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pen... more The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.
The Journal of Bone and Joint Surgery-American Volume, 2003
Severe deformity resulting from Paget disease is not uncommon. Malalignment of the extremity may ... more Severe deformity resulting from Paget disease is not uncommon. Malalignment of the extremity may lead to intractable pain, mechanical overload of the neighboring joints, limitation of motion and function, and dysmorphic appearance. Although corrective osteotomy has been used to treat osseous deformities, the outcome of corrective osteotomy for long-bone deformities resulting from Paget disease remains largely unknown. The results after twenty-five corrective osteotomies (twenty-two patients), performed between 1975 and 1995, in sixteen tibiae, eight femora, and one radius were evaluated. There were thirteen men and nine women with a mean age of sixty-seven years. The indication for osteotomy was pain in twenty limbs, recurrent stress fractures in three, and limitation of function in two. A variety of osteotomies and fixation methods were used. Two patients underwent simultaneous total hip arthroplasty and proximal femoral osteotomy. Twenty-three of twenty-five osteotomies healed with an average time to union of six months. Both nonunions were in patients who had been managed with intramedullary fixation. The time to union was significantly shorter in metaphyseal osteotomies fixed with plates than in diaphyseal osteotomies (p < 0.04). There was a substantial improvement in the deformities. Satisfaction was rated excellent or good by fourteen patients, fair by six, and poor by two. Complications included a pin-track infection in two patients, peroneal nerve palsy in one, and loss of fixation following external fixation in one. Disease activity, as measured by serum alkaline phosphatase level, and medical treatment with calcitonin and/or bisphosphonates did not have a significant impact on time to union. Corrective osteotomy for the treatment of severe deformity in Paget disease can be challenging and yet rewarding. A higher prevalence of complications was observed following intramedullary nailing and external fixation. Fracture-healing seems to be particularly protracted in diaphyseal osteotomies.
The aim of this study was to determine if there were significant differences in glenohumeral join... more The aim of this study was to determine if there were significant differences in glenohumeral joint morphology between North American and East Asian populations that may influence sizing and selection of shoulder arthroplasty systems. Computed tomography reconstructions of 92 North American and 58 East Asian patients were used to perform 3-dimensional measurements. The proximal humeral position was normalized in all patients by aligning it with the scapular plane utilizing anatomic landmarks. Measurements were performed on the humerus and scapula and included coronal and axial humeral head radius, humeral neck shaft and articular arc angles, glenoid height and width, and critical shoulder angle. Glenohumeral relationships were also measured and included lateral distance to the greater tuberosity and acromion, abduction lever arm, and acromial index. Parametric and nonparametric statistical analyses were used to compare population metrics. East Asian glenohumeral measurements were sig...
Journal of Bone Joint Surgery British Volume, Mar 1, 2004
Aims: Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was co... more Aims: Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP. Methods: 20 Primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis/anterior superior arch deþciency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed. Results: Primary RSP improvements/Revision RSP improvements were: 9.4 sf-36 PCS/6.3 sf-36 PCS, 1.8 SST/1.6 SST, 31.8 ASES/17.5 ASES (p Conclusion: Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with glenohumeral arthritis/anterior superior arch deþciency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes
Arthroplasty for the Treatment of Fractures in the Older Patient, 2018
Proximal humerus fractures account for 4–5% of all adult fractures. Knowledge of the anatomy is v... more Proximal humerus fractures account for 4–5% of all adult fractures. Knowledge of the anatomy is vital in determining treatment and achieving optimal surgical outcome. A thorough history and physical exam is the foundation for correct treatment. Indications for shoulder arthroplasty for proximal humerus fractures in appropriate surgical candidates include three- and four-part fracture-dislocations, head-splitting fractures, impaction fractures of the humeral head with involvement of more than 50% of the articular surface, displaced anatomic neck fractures, and select three- and four-part proximal humerus in which there is a high risk of osteonecrosis or failure of internal fixation. Hemiarthroplasty is performed except in patients who are greater than 70 years old with poor tuberosity bone quality due to osteoporosis or comminution, preexisting chronic rotator cuff tear, or preexisting osteoarthritis of the glenohumeral joint. In such cases, reverse shoulder arthroplasty is preferred. Anatomic or conventional total shoulder arthroplasty is not utilized in acute proximal humerus fractures. Success with shoulder hemiarthroplasty or reverse shoulder arthroplasty for proximal humerus fractures is largely dependent on surgical technique. Goals of either surgery are proper restoration of prosthetic height, proper version, secure tuberosity attachment, and accurate soft tissue balancing of the rotator cuff.
Background: The purpose of this study was to compare postoperative opioid consumption following t... more Background: The purpose of this study was to compare postoperative opioid consumption following total shoulder arthroplasty, after: (A) a single-shot undiluted liposomal bupivacaine (LB; commercial name: Exparel) interscalene block, or (B) a Ropivacaine block (R), supplemented with continuous catheter infusion. Methods: This prospective, randomized study (NCT03739021) compared postoperative analgesic requirements in Morphine Milligram Equivalent (MME) during the first 24 h after discharge from the post-anesthesia care unit (PACU) in patients receiving total shoulder arthroplasty. Two similar groups of 30 patients each received equivalent general operative anesthesia. Preoperative interscalene block was performed with either 10mL of undiluted liposomal bupivacaine (LB) or ropivacaine (R) 0.5% plus continuous catheter infusion. Results: There were no differences between the two groups regarding age, gender, length of surgery, intraoperative narcotic usage, or length of hospital stay. ...
The reverse total shoulder arthroplasty has been well established as a successful treatment for r... more The reverse total shoulder arthroplasty has been well established as a successful treatment for rotator cuff arthropathy (RCA). The native glenoid is infrequently normal in the setting of a massive rotator cuff tear, and bone loss has been reported to be as high as 40% in some studies (Frankle et al., J Shoulder Elb Surg 18:874–85, 2009; Klein et al., J Bone Joint Surg Am 92:1144–54, 2010). With superior migration of the humeral head, there tends to be a vertical wear pattern that differentiates this pathology from primary osteoarthritis. Failure to recognize this wear pattern can lead to an error in surgical technique and may result in inadequate glenoid fixation or superior tilt of the glenosphere. These errors can lead to poor patient outcomes and early failure of the implant.
Issues of Rehabilitation, Orthopaedics, Neurophysiology and Sport Promotion – IRONS, 2021
Introduction and aim This paper reports on 5 key aspects to consider when planning a successful R... more Introduction and aim This paper reports on 5 key aspects to consider when planning a successful RSA procedure, including patient selection, glenosphere positioning, glenoid fixation, humeral fixation, and soft tissue management/tensioning. Material, methods, results, and discussion Key in patient selection for RSA is understanding the relationship between indications, outcomes, patient mental state, and their expectations. When placing a glenosphere, prioritize sound principles of shoulder kinematics but always consider bone preservation and ease of placement. Glenoid fixation must take advantage of structural features of individual implant designs while factoring in specific-bone morphology/morphometry to optimize the resultant glenohumeral loading. For the stem, fixation prioritizes press-fit where bone quality and quantity permit. Always aim to achieve anatomical pivot point restoration with planning for stem position and avoid distalization that may lead to nerve injury and scap...
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pen... more The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.
The Journal of Bone and Joint Surgery-American Volume, 2003
Severe deformity resulting from Paget disease is not uncommon. Malalignment of the extremity may ... more Severe deformity resulting from Paget disease is not uncommon. Malalignment of the extremity may lead to intractable pain, mechanical overload of the neighboring joints, limitation of motion and function, and dysmorphic appearance. Although corrective osteotomy has been used to treat osseous deformities, the outcome of corrective osteotomy for long-bone deformities resulting from Paget disease remains largely unknown. The results after twenty-five corrective osteotomies (twenty-two patients), performed between 1975 and 1995, in sixteen tibiae, eight femora, and one radius were evaluated. There were thirteen men and nine women with a mean age of sixty-seven years. The indication for osteotomy was pain in twenty limbs, recurrent stress fractures in three, and limitation of function in two. A variety of osteotomies and fixation methods were used. Two patients underwent simultaneous total hip arthroplasty and proximal femoral osteotomy. Twenty-three of twenty-five osteotomies healed with an average time to union of six months. Both nonunions were in patients who had been managed with intramedullary fixation. The time to union was significantly shorter in metaphyseal osteotomies fixed with plates than in diaphyseal osteotomies (p < 0.04). There was a substantial improvement in the deformities. Satisfaction was rated excellent or good by fourteen patients, fair by six, and poor by two. Complications included a pin-track infection in two patients, peroneal nerve palsy in one, and loss of fixation following external fixation in one. Disease activity, as measured by serum alkaline phosphatase level, and medical treatment with calcitonin and/or bisphosphonates did not have a significant impact on time to union. Corrective osteotomy for the treatment of severe deformity in Paget disease can be challenging and yet rewarding. A higher prevalence of complications was observed following intramedullary nailing and external fixation. Fracture-healing seems to be particularly protracted in diaphyseal osteotomies.
The aim of this study was to determine if there were significant differences in glenohumeral join... more The aim of this study was to determine if there were significant differences in glenohumeral joint morphology between North American and East Asian populations that may influence sizing and selection of shoulder arthroplasty systems. Computed tomography reconstructions of 92 North American and 58 East Asian patients were used to perform 3-dimensional measurements. The proximal humeral position was normalized in all patients by aligning it with the scapular plane utilizing anatomic landmarks. Measurements were performed on the humerus and scapula and included coronal and axial humeral head radius, humeral neck shaft and articular arc angles, glenoid height and width, and critical shoulder angle. Glenohumeral relationships were also measured and included lateral distance to the greater tuberosity and acromion, abduction lever arm, and acromial index. Parametric and nonparametric statistical analyses were used to compare population metrics. East Asian glenohumeral measurements were sig...
Journal of Bone Joint Surgery British Volume, Mar 1, 2004
Aims: Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was co... more Aims: Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP. Methods: 20 Primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis/anterior superior arch deþciency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed. Results: Primary RSP improvements/Revision RSP improvements were: 9.4 sf-36 PCS/6.3 sf-36 PCS, 1.8 SST/1.6 SST, 31.8 ASES/17.5 ASES (p Conclusion: Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with glenohumeral arthritis/anterior superior arch deþciency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes
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