Long-Term Outcomes of Glenohumeral Arthrodesis
Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. https://bit.ly/2HuHYBb #JBJS
Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes
Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group. https://bit.ly/2I2hB50 #JBJS
Teaching Patients How to Reduce a Shoulder Dislocation
BHM self-administered technique can be used as a first-line technique in the emergency department for reducing shoulder dislocation. https://goo.gl/gwMt16 #JBJS
Video Summary: Teaching Patients How to Reduce a Shoulder Dislocation
BHM self-administered technique can be used as a first-line technique in the emergency department for reducing shoulder dislocations. https://goo.gl/CaCwnx #JBJSVideoSummaries #JBJS
JBJS 100: Cuff Tear Arthropathy and Cervical Spine Disorders
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Cuff Tear Arthropathy
Neer CS 2nd, Craig EV, Fukuda: JBJS, 1983 Dec; 65 (9): 1232
These authors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition.
The Treatment of Certain Cervical-spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion
Smith GW, Robinson RA: JBJS, 1958 June; 40 (3): 607
Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable. The versatile approach is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy.
Both Subjective and Objective Measures Tell the Shoulder Story
When surgeons and patients discuss what treatment will work best for a particular musculoskeletal ailment, they often rely on both “subjective” and “objective” outcome data from previously published assessments. Reviewing both types of data is a good idea, because a study among more than 100 patients with shoulder osteoarthritis by Matsen et al. in the March 1, 2017 issue of The Journal of Bone & Joint Surgery found poor correlation between objective measures of active abduction and subjective patient self-assessments using the Simple Shoulder Test (SST).
The authors used a statistical method called “coefficient of determination”
to confirm “a highly variable relationship” between the patient-reported SST (subjective) and motor-sensor range-of-motion (objective) measurements. In less statistical language, many of the shoulders had good motion and poor self-assessed function, while others had poor motion and good self-assessed function.
The findings led the authors to conclude that “studies of treatment outcomes should include separate assessments of these 2 complementary aspects of shoulder function.” That conclusion was seconded and expanded upon in a commentary by Jeffrey S. Abrams, MD, who wrote that “either [subjective or objective] assessment used independently may lead to the wrong impression.”
Guest Post: Single-Stage Revision for Failed Shoulder Arthroplasty Is Effective
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD.
Shoulder arthroplasty continues to grow in popularity, and as the number of shoulder arthroplasties rises, so will the number of revisions. Infection is one major reason for shoulder arthroplasty failure, and Propionibacterium has been increasingly recognized as a major culprit.
However, Propionibacterium infection is difficult to diagnose. Despite improved detection techniques, diagnosis at the time of revision remains elusive because obvious signs of acute infection are often absent. The need to perform explantation in the setting of clinically apparent periprosthetic infection is obvious, but the appropriateness of single-stage revision with antibiotic treatment in shoulders with only apparent mechanical failures remains questionable.
Hsu et al. attempted to address this question in a study published in the December 21, 2016 issue of JBJS. The group retrospectively reviewed the outcomes of 55 shoulders that underwent revision arthroplasty due to continued pain, stiffness, or component loosening without obvious clinical infection. Mean follow up was 48 months. At least five cultures were obtained intraoperatively during each revision, and each case was treated with antibiotics as if were truly infected until the final culture results were received after three weeks. Shoulders were revised to either hemi-arthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty.
Hsu et al. analyzed outcomes according to two groups: the positive cohort (n=27), where shoulders had ≥ 2 cultures positive for Propionibacterium, and the control cohort (n=28), where shoulders had either 0 or 1 positive culture. The two groups were compared by before- and after-revision performance on the simple shoulder test (SST) and pain outcome scores.
Both groups improved postoperatively based on these patient-reported outcome measures, and no significant difference was found between the two groups. Three patients in each group required a return to the OR. Gastrointestinal side effects were the most commonly reported complication from prolonged antibiotic administration.
This study design was limited by its retrospective nature and the lack of a two-stage revision treatment comparison group. Furthermore, this study included only patients with no signs of clinical infection, and the findings may not be applicable to patients with perioperative signs of infection. The study also incorporated three revision surgery implant options, which could have influenced postoperative SST and pain scores. Larger, multicenter controlled trials will be needed to produce a more definitive answer to this complicated question.
Still, there are clear benefits of single-stage revision over two-stage revision, especially with regard to operative time, anesthesia risks, and patient recovery. Given the wide antibiotic sensitivity profile of Propionibacterium and these initial results from Hsu et al., single-stage revision with appropriate antibiotic therapy may be suitable for patients undergoing revision shoulder arthroplasty in the setting of suspected Propionibacterium infection.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will complete a hand fellowship at the University of Chicago in 2017-2018.
JBJS Case Connections—Osteochondritis Dissecans: Baseball and Genetics
The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.
The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:
- Shoulder OCD in a teenage baseball player that was treated arthroscopically
- Early elbow OCD in young throwers
- Three cases of bilateral femoral head OCD that occurred in multiple members of the same family
Among the take-home points emphasized in this Case Connections article:
- MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
- Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
- There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.
JBJS JOPA Image Quiz: Lateral Clavicle Fracture
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 64-year-old woman who fell out of bed while sleeping and landed directly on the lateral aspect of the right shoulder. Based on the image shown here and a Zanca view radiograph, she was diagnosed in the emergency room with a lateral clavicle fracture. After staying in a sling for about two weeks, the patient continued to have shoulder pain when using the arm with overhead activities and when sleeping on the shoulder at night.
Select from among four choices as the next best step in treatment: MRI to evaluate the coracoclavicular ligaments, open reduction/internal fixation, continued sling treatment until pain resolves, or transacromial wire fixation.
Whence P. Acnes in Shoulder Arthroplasty?
Propionibacterium acnes is a frequently isolated pathogen in postoperative shoulder infections, but where exactly does it come from? According to a study by Falconer et al. in the October 19, 2016 Journal of Bone & Joint Surgery, P. acnes derives from the subdermal edges of the surgical incision and spreads through contact with the surgeon’s gloves and surgical instruments.
The authors obtained specimens for microbiological analysis at five different sites from 40 patients undergoing primary shoulder arthroplasty. Thirty-three percent of the patients had at least one culture specimen positive for P. acnes, and the most common site of P. acnes growth was the subdermal layer, followed by forceps.
The authors observed no clinical postoperative infections during the follow-up of 6 to 18 months, although that is a relatively short investigation period for a pathogen that often causes late-onset indolent infections. The authors conclude that “it is likely that surgeon handling of the skin and subdermal layer contaminates the rest of the surgical field.” Although the study did not investigate preventive techniques, based on the findings the authors suggest the following possible prophylactic approaches:
- Minimizing handling of the subdermal layer
- Changing gloves after the dermis is cut
- Avoiding contact between implants and the subdermal layer
- Repeating use of antibacterial agents once the wound is opened
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