BACKGROUND:Treating shoulders with osteoarthritis, an intact rotator cuff, and substantial glenoid bone loss is challenging. One option is reaming the glenoid flat and inserting a reverse prosthesis. ...This study reports the subjective, objective, and radiographic results of reverse total shoulder arthroplasty (RTSA) in this population.
METHODS:We retrospectively reviewed 42 consecutive patients (23 women; mean age, 71 years range, 53 to 89 years) with primary glenohumeral osteoarthritis, intact rotator cuffs, and Walch type-A2 (n = 19), B2 (n = 5), or C glenoids (n = 18) who had undergone a total of 42 RTSAs with glenoid reaming without bone-grafting between 2008 and 2013 (mean follow-up, 36 months range, 24 to 66 months). All patients were evaluated before and after surgery subjectively (using a visual analog scale for pain and 5 shoulder-specific outcome instruments), objectively (with goniometric examination of shoulder range of motion), and radiographically (to assess baseplate loosening and degree of scapular notching).
RESULTS:One baseplate (2%) failed, requiring revision surgery. There were no other signs of baseplate loosening in any patient at the last follow-up. Preoperatively to postoperatively, pain improved significantly (p < 0.001), as did all patient-reported outcome measures and the following range-of-motion parameters (p ≤ 0.001)active abduction, active flexion, and active external rotation with the arm elevated 90°. Eight (19%) of the patients had notching.
CONCLUSIONS:RTSA without bone-grafting and with medialization of the baseplate in patients with osteoarthritis and severe glenoid bone loss resulted in significant improvement in pain and function with reliable short-term implant survivorship and may be a good alternative to anatomical TSA. Longer follow-up is needed to determine the relative advantages and disadvantages. This was an “off-label” indication for this device.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Introduction This study was developed to test the hypothesis that there is a period in which a painful, traumatic rotator cuff tear, with associated weakness and the inability to abduct above ...shoulder level, should be repaired to allow for improvement in function. Methods Forty-two consecutive, prospectively followed patients met the criteria for entrance into this study. Of those, 36 patients were available for a minimum 9 months follow-up (average, 31 months; range, 9–71) by office visit. Patient outcomes were measured using the UCLA End-Result and ASES scoring systems. Patient variables, including time from injury to repair, tear size, degree of preoperative fat infiltration, patient satisfaction, and improvement in pain, were evaluated for their association with surgical outcome using independent t testing. Time to repair was evaluated at 0–2 months, 2–4 months, and greater than 4 months. Results Pain scores improved from 7 to 1.4 ( P < .01) and active elevation improved from 55° to 133° ( P < .01). UCLA/ASES scores improved from 8/30 to 26/79, respectively ( P < .01, P < .01). All but 2 of the 36 patients were satisfied with their result. Preoperative fatty atrophy did not correlate with postoperative function. Rotator cuff tear size had no influence on patient outcome if repaired before 4 months. Massive tears repaired after 4 months had the worst outcome. Conclusion Our results emphasize that the treatment outcome for traumatic rotator cuff tears of all sizes, with associated weakness, is not compromised up to 4 months after their injury.
Event-related fMRI studies reveal that episodic memory retrieval modulates lateral and medial parietal cortices, dorsal middle frontal gyrus (MFG), and anterior PFC. These regions respond more for ...recognized old than correctly rejected new words, suggesting a neural correlate of retrieval success. Despite significant efforts examining retrieval success regions, their role in retrieval remains largely unknown. Here we asked the question, to what degree are the regions performing memory-specific operations? And if so, are they all equally sensitive to successful retrieval, or are other factors such as error detection also implicated? We investigated this question by testing whether activity in retrieval success regions was associated with task-specific contingencies (i.e., perceived targetness) or mnemonic relevance (e.g., retrieval of source context). To do this, we used a source memory task that required discrimination between remembered targets and remembered nontargets. For a given region, the modulation of neural activity by a situational factor such as target status would suggest a more domain-general role; similarly, modulations of activity linked to error detection would suggest a role in monitoring and control rather than the accumulation of evidence from memory per se. We found that parietal retrieval success regions exhibited greater activity for items receiving correct than incorrect source responses, whereas frontal retrieval success regions were most active on error trials, suggesting that posterior regions signal successful retrieval whereas frontal regions monitor retrieval outcome. In addition, perceived targetness failed to modulate fMRI activity in any retrieval success region, suggesting that these regions are retrieval specific. We discuss the different functions that these regions may support and propose an accumulator model that captures the different pattern of responses seen in frontal and parietal retrieval success regions.
Background
Current surgical treatments for acromioclavicular separations do not re-create the anatomy of the acromioclavicular joint.
Hypothesis
Anatomical acromioclavicular reconstruction re-creates ...the strength of the native acromioclavicular joint and is stronger than a modified Weaver-Dunn repair.
Study Design
Controlled laboratory study.
Methods
The native acromioclavicular joint in 6 fresh-frozen cadaveric upper extremities was stressed to failure under uniaxial tension in the coronal plane. A modified Weaver-Dunn procedure, anatomical acromioclavicular reconstruction using a palmaris longus graft, and anatomical acromioclavicular reconstruction using a flexor carpi radialis graft were then performed sequentially. Each repair was stressed to failure. Load-displacement curves and mechanism of failure were recorded for each.
Results
Loads at failure for the native acromioclavicular joint complex, modified Weaver-Dunn procedure, anatomical acromioclavicular reconstruction using a palmaris longus tendon graft, and anatomical acromioclavicular reconstruction using a flexor carpi radialis tendon graft were 815 N, 483 N, 326 N, and 774 N, respectively. The strength of the native acromioclavicular joint complex was significantly different from the modified Weaver-Dunn repair (P <. 001) and the anatomical acromioclavicular reconstruction using a palmaris longus tendon graft (P <. 001) but not from the anatomical acromioclavicular reconstruction using a flexor carpi radialis tendon graft (P =. 607).
Conclusion
The strength of the described anatomical acromioclavicular reconstruction is limited by the tendon graft used. Anatomical acromioclavicular reconstruction with a flexor carpi radialis tendon graft re-creates the tensile strength of the native acromioclavicular joint complex and is superior to a modified Weaver-Dunn repair.
Objective:The infant temperament behavioral inhibition is a potent risk factor for development of an anxiety disorder. It is difficult to predict risk for behavioral inhibition at birth, however, and ...the neural underpinnings are poorly understood. The authors hypothesized that neonatal functional connectivity of the ventral attention network is related to behavioral inhibition at age 2 years beyond sociodemographic and familial factors. This hypothesis is supported by the ventral attention network’s role in attention to novelty, a key feature of behavioral inhibition.Method:Using a longitudinal design (N=45), the authors measured functional connectivity using MRI in neonates and behavioral inhibition at age 2 using the Infant-Toddler Social and Emotional Assessment. Whole-brain connectivity maps were computed for regions from the ventral attention, default mode, and salience networks. Regression analyses related these maps to behavioral inhibition at age 2, covarying for sex, social risk, and motion during scanning.Results:Decreased neonatal functional connectivity of three connections was associated with increased behavioral inhibition at age 2. One connection (between the right ventrolateral prefrontal cortex and the right temporal-parietal junction) included the ventral attention network seed, and two connections (between the medial prefrontal cortex and both the right superior parietal lobule and the left lateral occipital cortex) included the default mode network seed.Conclusions:Neonatal functional connectivity of the ventral attention and default mode networks is associated with behavioral inhibition at age 2. These results inform the developmental neurobiology of behavioral inhibition and anxiety disorders and may aid in early risk assessment and intervention.
Background
For hip and knee arthroplasties, an American Society of Anesthesiologists (ASA) score greater than 2 is associated with an increased risk of medical and surgical complications. No study, ...to our knowledge, has evaluated this relationship for total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (reverse TSA).
Questions/purposes
We aimed to assess the relationship between the ASA score and (1) surgical complications, (2) medical complications, and (3) hospitalization length after TSA, reverse TSA, and revision arthroplasty.
Methods
We retrospectively analyzed all patients who had undergone TSAs, reverse TSAs, or revision arthroplasties by the senior author (EGM) from November 1999 through July 2011 who had at least 6 months’ followup. Of the 485 procedures, 452 (93.2%) met the inclusion criteria. Data were collected on patient demographics, comorbidities, hospitalization length, and short-term (≤ 6 months) medical and surgical complications. Logistic regression analysis modeled the risk of having postoperative complications develop as a function of the ASA score.
Results
Patients with an ASA score greater than 2 had a greater risk of having a surgical complication develop (p < 0.001; OR, 2.27; 95% CI, 1.36–3.70) and three times the risk of prosthesis failure (ie, component dislocation, component loosening, and hardware failure) (p < 0.001; OR, 3.23; 95% CI, 1.54–6.67). Higher ASA scores were associated with prolonged length of hospitalization (effect size 0.46, p < 0.001), but not medical complications.
Conclusions
ASA score is associated with surgical, but not medical, complications after TSA and reverse TSA. The ASA score could be used for risk assessment and preoperative counseling.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Background Treating anterior glenoid bone loss in patients with recurrent shoulder instability is challenging. Coracoid transfer techniques are associated with neurologic complications and ...neuroanatomic alterations. The purpose of our study was to compare the contact area and pressures of a distal clavicle autograft with a coracoid bone graft for the restoration of anterior glenoid bone loss. We hypothesized that a distal clavicle autograft would be as effective as a coracoid graft. Methods In 13 fresh-frozen cadaveric shoulder specimens, we harvested the distal 1.0 cm of each clavicle and the coracoid bone resection required for a Latarjet procedure. A compressive load of 440 N was applied across the glenohumeral joint at 30° and 60° of abduction, as well as 60° of abduction with 90° of external rotation. Pressure-sensitive film was used to determine normal glenohumeral contact area and pressures. In each specimen, we created a vertical, 25% anterior bone defect, reconstructed with distal clavicle (articular surface and undersurface) and coracoid bone grafts, and determined the glenohumeral contact area and pressures. We used analysis of variance for group comparisons and a Tukey post hoc test for individual comparisons (with P < .05 indicating a significant difference). Results The articular distal clavicle bone graft provided the lowest mean pressure in all testing positions. The coracoid bone graft provided the greatest contact area in all humeral positions, but the difference was not significant. Conclusion An articular distal clavicle bone graft is comparable in glenohumeral contact area and pressures to an optimally placed coracoid bone graft for restoring glenoid bone loss. Level of evidence Basic Science Study; Biomechanics
Background The aim of this study is to document a single surgeon's experience performing revision reverse shoulder arthroplasty after baseplate failure. Methods Revision reverse shoulder arthroplasty ...(RSA) for mechanical failure of the glenoid baseplate after RSA was performed in 14 patients. Clinical and radiographic data were collected preoperatively, prior to baseplate failure, after baseplate failure, and at latest follow-up after revision (average, 33 months). Results When comparing the pre-operative values to post-revision, ASES, forward elevation, and abduction were significantly improved. There was no significant difference in any of the outcome measures when comparing the prefailure data to the post-revision data. The post-revision prosthesis-scapular neck angle (PSNA) showed a significant increase in inferior tilt of the baseplate when compared to pre-failure PSNA (P < .001). Two patients (14%) required a second revision RSA for glenoid baseplate failure (1) and dislocation (1); 1 additional patient developed a postoperative hematoma which resolved without surgery. Conclusion Revision RSA for the treatment of glenoid baseplate mechanical failure can restore pain relief and function to the levels gained after the index RSA. Level of evidence Level IV, Case Series, Treatment Study.
The aim of this study was to compare liposomal bupivacaine and interscalene nerve block (ISNB) for analgesia after shoulder arthroplasty. We compared 37 patients who received liposomal bupivacaine vs ...21 who received ISNB after shoulder arthroplasty by length of hospital stay (LOS), opioid consumption, and postoperative pain. Pain was the same in both groups for time intervals of 1 hour and 8 to 14 hours postoperatively. Compared with ISNB patients, liposomal bupivacaine patients reported less pain at 18 to 24 hours (P = .001) and 27 to 36 hours (P = .029) and had lower opioid consumption on postoperative days 2 (P = .001) and 3 (P = .002). Mean LOS for liposomal bupivacaine patients was 46 ± 20 hours vs 57 ± 14 hours for ISNB patients (P = .012). Sixteen of 37 liposomal bupivacaine patients vs 2 of 21 ISNB patients were discharged on the first postoperative day (P = .010). Liposomal bupivacaine was associated with less pain, less opioid consumption, and shorter hospital stays after shoulder arthroplasty compared with ISNB.
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