Publications by authors named "Joaquin Sanchez-Sotelo"

235 Publications

3D Muscle Loss (3DML) assessment: A novel CT-based quantitative method to evaluate rotator cuff muscle fatty infiltration.

J Shoulder Elbow Surg 2021 Aug 31. Epub 2021 Aug 31.

IMT Atlantique, LaTIM INSERM U1101, Brest, France.

Introduction: Rotator cuff fatty infiltration (FI) is one of the most important parameters to predict the outcome of certain shoulder conditions. The primary objective of this study was to define a new computed tomography (CT)-based quantitative 3-dimensional (3D) measure of muscle loss (3DML) based on the rationale of the 2-dimensional (2D) qualitative Goutallier score. The secondary objective of this study was to compare this new measurement method to traditional 2D qualitative assessment of FI according to Goutallier et al and to a 3D quantitative measurement of fatty infiltration (3DFI).

Materials And Methods: 102 CT scans from healthy shoulders (46) and shoulders with cuff tear arthropathy (21), irreparable rotator cuff tears (18), and primary osteoarthritis (17) were analyzed by three experienced shoulder surgeons for subjective grading of fatty infiltration according to Goutallier and their rotator cuff muscles were manually segmented. Quantitative 3D measurements of fatty infiltration (3DFI) were completed. The volume of muscle fibers without intra-muscular fat was then calculated for each rotator cuff muscle and normalized to the patient's scapular volume to account for the effect of body size (NV). Three-dimensional muscle mass (3DMM) was calculated by dividing the NV value of a given muscle by the mean expected volume in healthy shoulders. Three-dimensional muscle loss (3DML) was defined as 1-(3DMM). The correlation between Goutallier grading, 3DFI, and 3DML was compared using a Spearman Rank correlation.

Results: Interobserver reliability for the traditional 2D Goutallier grading was moderate for the infraspinatus (ISP=0.42) and fair for the supraspinatus (SSP=0.38), subscapularis (SSC=0.27) and teres minor (TM=0.27). 2D Goutallier grading was found to be significantly and highly correlated with 3DFI (SSP=0.79, ISP=0.83, SSC=0.69, TM=0.45) and 3DML (SSP=0.87, ISP=0.85, SSC=0.69, TM=0.46) for all four rotator cuff muscles (p<0.0001). This correlation was significantly higher for 3DML than for the 3DFI for the SSP only (p=0.01). The mean values of 3DFI and 3DML were 0.9% and 5.3% for Goutallier-0, 2.9% and 25.6% for Goutallier-1, 11.4% and 49.5% for Goutallier-2, 20.7% and 59.7% for Goutallier-3, and 29.3% and 70.2% for Goutallier-4, respectively.

Conclusion: The Goutallier score has been helping surgeons by using 2-dimensional CT-scan slices. However, this grading is associated with suboptimal interobserver agreement. The new measures we propose provide a more consistent assessment that correlates well with Goutallier's principles. As 3DML measurements incorporate atrophy and fatty infiltration, they could become a very reliable index for assessing shoulder muscle function. Future algorithms capable of automatically calculating the 3DML of the cuff could help in the decision process for cuff repair and the choice of anatomic or reverse shoulder arthroplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.07.029DOI Listing
August 2021

Total elbow arthroplasty for tumors of the distal humerus and elbow.

J Surg Oncol 2021 Aug 23. Epub 2021 Aug 23.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: The elbow is a rare location for primary and metastatic tumors in the upper extremity. The goal of reconstruction is to provide painless motion and stability for hand function. Total elbow arthroplasty (TEA) is commonly utilized, with either off-the-self components, modular segmental endoprosthesis, or allograft-prosthesis composites (APC). The purpose of this study was to analyze and compare commonly utilized elbow reconstructions and report outcomes of (1) patient function and (2) implant survival and complications.

Methods: We reviewed 33 patients (18 females and 15 males) undergoing elbow arthroplasty for reconstruction of an underlying oncologic process including linked TEA (n = 22, 67%), APC (n = 9, 27%), and endoprosthesis (n = 2, 6%). The most common indication was metastatic disease (n = 17, 52%), with 24 patients (73%) presenting with a pathologic fracture.

Results: Five-year implant survival was following elbow reconstruction was 88%. The mean most recent Mayo Elbow Performance Score and Musculoskeletal Tumor Society Score were 84 ± 18 and 78 ± 15%. Postoperative complications occurred in 15 elbows (45%), most commonly periprosthetic fracture (n = 5, 15%), leading to reoperation in six elbows (18%).

Conclusion: Although elbow arthroplasty is associated with a high incidence of complications, it provides a stable platform for upper extremity function in patients with oncologic processes of the elbow.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26658DOI Listing
August 2021

Shoulder Arthroplasty in Patients with Juvenile Idiopathic Arthritis:Long-Term Outcomes.

J Shoulder Elbow Surg 2021 Jul 20. Epub 2021 Jul 20.

Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Background: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease that occurs in the pediatric population. Often, JIA continues throughout life leading to progressive polyarticular arthritis and significant joint destruction and disability, oftentimes requiring replacement surgery. This study aimed to determine the outcomes of primary shoulder arthroplasty (SA) in patients with JIA.

Methods: Over a 42-year time period (1977 - 2019), 67 primary SA (20 hemiarthroplasty (HA), 38 anatomic total shoulder arthroplasty (TSA), and 9 reverse shoulder arthroplasty (RSA)) with a prior diagnosis of JIA formally established in a multi-disciplinary rheumatologic clinic met inclusion criteria. Further assessment was performed with inclusion of the visual analog scale (VAS) pain score, active shoulder range of motion (ROM), imaging studies, complications, and implant survivorship free from reoperation and revision.

Results: SA led to substantial improvements in pain and ROM across the entire cohort at an average follow-up period of 12.2 years (range, 2- 34 years). TSA was associated with the lowest pain scores (0.8; p = 0.02) and the highest ASES scores (77.4; p = 0.04) at most recent follow-up when compared to HA and RSA. There were 14 (21%) complications across the cohort with rotator cuff failure (n=4; 5.9%) as the most common complication followed by infection (n=3; 4.5%). Revision surgery was performed in 5 shoulders (7.5%), with five-year implant survival rates of 95.1% at five years, 93% at ten years, 89.4% at twenty years, and 79.5% at thirty years. At 30 years, TSA was associated with better survival (90.1%) when compared with HA (71.8%).

Conclusions: Primary shoulder arthroplasty in the form of HA, TSA, and RSA offers a reliable surgical option for JIA patients with respect to pain reduction and ROM improvements. Unique challenges still exist in this cohort, in particular younger patients with an elevated propensity for glenoid bone erosion and a complication rate of 20.9%. As such, HA may not be ideal in this patient population. However, despite rotator cuff and glenoid concerns, TSA seems to be associated with better pain relief and patient reported outcomes with the most durability in the long term when compared to HA.

Level Of Evidence: Level III; Retrospective Cohort Comparison; Treatment Study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.06.014DOI Listing
July 2021

Prevalence of Shoulder Arthroplasty in the United States and the Increasing Burden of Revision Shoulder Arthroplasty.

JB JS Open Access 2021 Jul-Sep;6(3). Epub 2021 Jul 14.

Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia.

Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States.

Methods: The National Inpatient Sample (NIS) was queried to count all patients who underwent total shoulder arthroplasty (TSA), including both anatomic and reverse TSA, and hemiarthroplasty between 1988 and 2017. The counting method was used to calculate the current prevalence of TSA and hemiarthroplasty using age and sex-specific population and mortality data from the U.S. Census Bureau.

Results: In 2017, an estimated 823,361 patients (95% confidence interval [CI], 809,267 to 837,129 patients) were living in the United States with a shoulder replacement. This represents a prevalence of 0.258%, increasing markedly from 1995 (0.031%) and 2005 (0.083%). Female patients had a higher prevalence at 0.294% than male patients at 0.221%. Over 2% of people who were ≥80 years of age in the United States were living with a shoulder replacement. Furthermore, approximately 60% of patients living with a shoulder replacement had undergone the operation between 2013 and 2017. The incidence of revision shoulder arthroplasty is increasing on an annual basis, with 10,290 revision procedures performed in 2017, costing the U.S. health-care system $205 million.

Conclusions: The prevalence of shoulder arthroplasty in the United States has markedly increased over time. This trend will likely continue given increasing life expectancies and exponentially increasing shoulder arthroplasty incidence rates. Most patients do not have long-term follow-up, and revision shoulder arthroplasty rates are increasing, a trend that is projected to continue. The data from our study highlight the enormous public health impact of shoulder replacement and shed light on a potentially increasing revision burden.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.OA.20.00156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280071PMC
July 2021

The effects of shoulder arthroscopy on ultrasound image quality of the interscalene brachial plexus: a pre-procedure vs post-procedure comparative study.

BMC Anesthesiol 2021 07 9;21(1):187. Epub 2021 Jul 9.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Background: Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative).

Methods: This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes.

Results: Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05).

Conclusion: Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible.

Trial Registration: ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12871-021-01409-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268244PMC
July 2021

Targeted next generation sequencing for elbow periprosthetic joint infection diagnosis.

Diagn Microbiol Infect Dis 2021 Oct 5;101(2):115448. Epub 2021 Jun 5.

Division of Clinical Microbiology, Mayo Clinic, Rochester, MN, USA; Infectious Diseases, Mayo Clinic, Rochester, MN, USA. Electronic address:

16S ribosomal RNA (rRNA) gene PCR followed by next-generation sequencing (NGS) was compared to culture of sonicate fluid derived from total elbow arthroplasty for periprosthetic joint infection (PJI) diagnosis. Sonicate fluids collected from 2007 to 2019 from patients who underwent revision of a total elbow arthroplasty were retrospectively analyzed at a single institution. PCR amplification of the V1-V3 region of the 16S rRNA gene was performed, followed by NGS using an Illumina MiSeq. Results were compared to those of sonicate fluid culture using McNemar's test of paired proportions. Forty-seven periprosthetic joint infections and 58 non-infectious arthroplasty failures were studied. Sensitivity of targeted NGS was 85%, compared to 77% for culture (P = 0.045). Specificity and positive and negative predictive values of targeted NGS were 98, 98 and 89%, respectively, compared to 100, 100 and 84%, respectively, for culture. 16S rRNA gene-based targeted metagenomic analysis of sonicate fluid was more sensitive than culture.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.diagmicrobio.2021.115448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429173PMC
October 2021

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty.

J Clin Orthop Trauma 2021 Sep 12;20:101477. Epub 2021 Jun 12.

Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcot.2021.101477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237363PMC
September 2021

Return to Sports After Primary Reverse Shoulder Arthroplasty: Outcomes at Mean 4-Year Follow-up.

Orthop J Sports Med 2021 Jun 10;9(6):23259671211012393. Epub 2021 Jun 10.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: With the expanding use of reverse shoulder arthroplasty (RSA) to treat various shoulder conditions, there has been a rise in the number of RSAs performed, especially in physically active patients. Limited information regarding sports after RSA is available to properly counsel patients on postoperative expectations.

Purpose: To assess the rate of return to sports as well as the ability to return to the same level of preoperative intensity, frequency, and duration of sport after primary RSA.

Study Design: Case series; Level of evidence, 4.

Methods: This was a retrospective review of patients who underwent primary RSA at our institution between 2014 and 2016. Shoulder motion, Subjective Shoulder Value score, American Shoulder and Elbow Surgeons score, pre- and postoperative sports activities, and barriers to return to sport were assessed in 109 patients after RSA (93 patients with unilateral RSA and 16 patients with bilateral RSA). The mean age at the time of surgery was 70 years (range, 34-86 years), with a mean follow-up of 3.9 years (range, 2-12 years).

Results: The mean rate of return to sports was 70.1% (range, 0%-100%). There was no difference in return to sports between those with uni- and bilateral RSA ( = .64). Fishing, swimming, elliptical/treadmill, and hunting were the most common sports after RSA with return rates of 91%, 73%, 86%, and 82% respectively. A majority of patients returned to the same level of preoperative intensity, frequency, and duration for all sports except for climbing and swimming. There was a lower mean rate of return for high-demand sports (62.9%) compared with low- and medium-demand sports (76.7%) ( = .005). The most common reasons for inability to return to sports included limited motion, fear of injury, and weakness.

Conclusion: Patients who had undergone primary uni- or bilateral RSA reported a 70.1% rate of return to sports with maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/23259671211012393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202274PMC
June 2021

Both Debridement and Microfracture Produce Excellent Results for Osteochondritis Dissecans Lesions of the Capitellum: A Systematic Review.

Arthrosc Sports Med Rehabil 2021 Apr 16;3(2):e593-e603. Epub 2021 Mar 16.

Department of Orthopedics, Mayo Clinic Sports Medicine Center, Rochester, Minnesota, U.S.A.

Purpose: To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD).

Methods: A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded.

Results: Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from -4° to 6° of flexion and -0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations.

Conclusions: Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects.

Level Of Evidence: Level IV, systematic review of studies, all Level IV evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.asmr.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128994PMC
April 2021

Radial Head Replacement for Acute Radial Head Fractures: Outcome and Survival of Three Implant Designs With and Without Cement Fixation.

J Orthop Trauma 2021 06;35(6):e202-e208

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Objectives: To determine outcomes of radial head replacement (RHR) for acute fractures using 3 different implant designs with or without cement fixation.

Design: Retrospective.

Setting: Tertiary referral hospital.

Patients/participants: One hundred fourteen elbows underwent RHR for an acute radial head fracture using either (1) a nonanatomic design and smooth stem (n = 60), (2) a nonanatomic design with a grit-blasted, ingrowth, curved stem (n = 21), or (3) an anatomic design with a grit-blasted ingrowth straight stem (n = 33). Cemented (25%) or uncemented (75%) fixation was used at the discretion of the treating surgeon.

Intervention: RHR.

Main Outcome Measurements: The primary outcome was implant survivorship free of revision or removal for any reason. All elbows were evaluated clinically (the Mayo Elbow Performance Score and reoperations/complications) and radiographically.

Results: Fourteen implants (12%) were revised. Of elbows with a minimum 2-year clinical follow-up, the average Mayo Elbow Performance Score was 88. The rate of survivorship free from revision was 92% [95% confidence interval (CI) = 87%-98%] at 2 years, 90% (CI = 84%-96%) at 5 years and 84% (CI = 75%-94%) at 10 years. The differences in survivorship between the 3 implants did not reach statistical significance, but the nonanatomic design with a grit-blasted ingrowth curved stem had a hazard ratio of 4.6 (95% CI = 0.9%-23%) for failure. There were no differences in survivorship between cemented versus uncemented stems. For those elbows with a minimum of 2 years of radiographic follow-up, implant tilt was observed in 10 (16%) elbows and loosening in 16 (26%) elbows. Stress shielding was present in 19 (42%) of well-fixed implants.

Conclusions: RHR for acute trauma leads to survivorship greater than 80% at 10 years. Radiographic changes (loosening, stress shielding, and implant tilting) can be expected in a substantial portion of elbows at long-term follow-up.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115875PMC
June 2021

Radiological humeral adaptative changes five years after anatomical total shoulder arthroplasty using a standard-length cementless hydroxyapatite-coated humeral component.

Bone Joint J 2021 May;103-B(5):958-963

Mayo Clinic, Rochester, Minnesota, USA.

Aims: The purpose of this study was to report bone adaptive changes after anatomical total shoulder arthroplasty (TSA) using a standard-length hydroxyapatite (HA)-coated humeral component, and to report on a computer-based analysis of radiographs to determine changes in peri-implant bone density objectively.

Methods: A total of 44 TSAs, performed between 2011 and 2014 using a cementless standard-length humeral component proximally coated with HA, were included. There were 23 males and 21 females with a mean age of 65 years (17 to 65). All shoulders had good quality radiographs at six weeks and five years postoperatively. Three observers graded bone adaptive changes. All radiographs were uploaded into a commercially available photographic software program. The grey value density of humeral radiological areas was corrected to the grey value density of the humeral component and compared over time.

Results: Stress shielding was graded as mild in 14 shoulders and moderate in three; the greater tuberosity was the predominant site for stress shielding. The mean metaphyseal and diaphyseal fill-fit ratios were 0.56 (SD 0.1) and 0.5 (SD 0.07), respectively. For shoulders with no radiologically visible stress shielding, the mean decrease in grey value in zones 1 and 7 was 20%, compared with 38% in shoulders with radiologically visible stress shielding.

Conclusion: The rate of moderate stress shielding was 7%, five years after implantation of a cementless standard-length HA-coated humeral component. Clinical observation of stress shielding identified on radiographs seems to represent a decrease in grey value of 25% or more. Cite this article:  2021;103-B(5):958-963.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1302/0301-620X.103B5.BJJ-2020-1619.R1DOI Listing
May 2021

Biomechanical, histological, and molecular characterization of a new posttraumatic model of arthrofibrosis in rats.

J Orthop Res 2021 Apr 19. Epub 2021 Apr 19.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Experimental analyses of posttraumatic knee arthrofibrosis utilize a rabbit model as a gold standard. However, a rodent model of arthrofibrosis offers many advantages including reduced cost and comparison with other models of organ fibrosis. This study aimed to characterize the biomechanical, histological, and molecular features of a novel posttraumatic model of arthrofibrosis in rats. Forty eight rats were divided into two equal groups. An immobilization procedure was performed on the right hind limbs of experimental rats. One group was immobilized for 4 weeks and the other for 8 weeks. Both groups were remobilized for 4 weeks. Limbs were studied biomechanically via assessment of torque versus degree of extension, histologically via whole knee specimen, and molecularly via gene expression of posterior capsular tissues. Significant differences were observed between experimental and control limbs at 4 N-cm of torque in the 4-week (knee extension: 115° ± 8° vs. 169° ± 17°, respectively; p = 0.007) and 8-week immobilization groups (knee extension: 99° ± 12° vs. 174° ± 9°, respectively; p = 0.008). Histologically, in each group experimental limbs demonstrated increased posterior capsular thickness and total area of tissue when compared to control limbs (p < 0.05). Gene expression values evaluated in each group were comparable. This study presents a novel rat model of arthrofibrosis with severe and persistent knee contractures demonstrated biomechanically and histologically. Statement of clinical significance: Arthrofibrosis is a common complication following contemporary total knee arthroplasties. The proposed model is reproducible, cost-effective, and can be employed for translational investigations studying the pathogenesis of arthrofibrosis and efficacy of neoadjuvant pharmacologic agents.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jor.25054DOI Listing
April 2021

Elevated Expression of Plasminogen Activator Inhibitor (PAI-1/SERPINE1) is Independent from rs1799889 Genotypes in Arthrofibrosis.

Meta Gene 2021 Jun 5;28. Epub 2021 Mar 5.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.

Arthrofibrosis is characterized by excessive extracellular matrix deposition in patients with total knee arthroplasties (TKAs) and causes undesirable joint stiffness. The pathogenesis of arthrofibrosis remains elusive and currently there are no diagnostic biomarkers for the pathological formation of this connective tissue. Fibrotic soft tissues are known to have elevated levels of plasminogen activator inhibitor-1 (PAI-1) (encoded by ), a secreted serine protease inhibitor that moderates extracellular matrix remodeling and tissue homeostasis. The 4G/5G insertion/deletion (rs1799889) is a well-known polymorphism that directly modulates PAI-1 levels. Homozygous 4G/4G allele carriers typically have higher PAI-1 levels and may predispose patients to soft tissue fibrosis (e.g., liver, lung, and kidney). Here, we examined the genetic contribution of the rs1799889 polymorphism to musculoskeletal fibrosis in arthrofibrotic (n = 100) and non-arthrofibrotic (n = 100) patients using Sanger Sequencing. Statistical analyses revealed that the allele frequencies of the rs1799889 polymorphism are similar in arthrofibrotic and non-arthrofibrotic patient cohorts. Because the fibrosis related rs1799889 polymorphism is independent of arthrofibrosis susceptibility in TKA patients, the possibility arises that fibrosis of joint connective tissues may involve unique genetic determinants distinct from those linked to classical soft tissue fibrosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.mgene.2021.100877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011541PMC
June 2021

Identification of threshold pathoanatomic metrics in primary glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2021 Oct 2;30(10):2270-2282. Epub 2021 Apr 2.

Hôpital Privé Jean Mermoz-Generale De Santé (GDS) Ramsay, Lyon, France.

Background: An assessment of the pathoanatomic parameters of the arthritic glenohumeral joint (GHJ) has the potential to identify discriminating metrics to differentiate glenoid types in shoulders with primary glenohumeral osteoarthritis (PGHOA). The aim was to identify the morphometric differences and threshold values between glenoid types including normal and arthritic glenoids with the various types in the Walch classification. We hypothesized that there would be clear morphometric discriminators between the various glenoid types and that specific numeric threshold values would allow identification of each glenoid type.

Methods: The computed tomography scans of 707 shoulders were analyzed: 585 obtained from shoulders with PGHOA and 122 from shoulders without glenohumeral pathology. Glenoid morphology was classified according to the Walch classification. All computed tomography scans were imported in a dedicated automatic 3D-software program that referenced measurements to the scapular body plane. Glenoid and humeral modeling was performed using the best-fit sphere method, and the root-mean-square error was calculated. The direction and orientation of the glenoid and humerus described glenohumeral relationships.

Results: Among shoulders with PGHOA, 90% of the glenoids and 85% of the humeral heads were directed posteriorly in reference to the scapular body plane. Several discriminatory pathoanatomic parameters were identified: GHJ narrowing < 3 mm was a discriminatory metric for type A glenoids. Posterior humeral subluxation > 70% discriminated type B1 from normal GHJs. The root-mean-square error was a discriminatory metric to distinguish type B2 from type A, type B3, and normal GHJs. Type B3 glenoids differed from type A2 by greater retroversion (>13°) and subluxation (>71%). The type C glenoid retroversion inferior limit was 21°, whereas normal glenoids never presented with retroversion > 16°.

Conclusion: Pathoanatomic metrics with the identified threshold values can be used to discriminate glenoid types in shoulders with PGHOA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.03.140DOI Listing
October 2021

Shoulder arthroplasty is a viable option in patients with Ehlers-Danlos syndrome.

J Shoulder Elbow Surg 2021 Apr 1. Epub 2021 Apr 1.

Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Background: Patients with Ehlers-Danlos syndrome (EDS) have high rates of shoulder instability, which place them at increased risk for instability-related arthropathy. Many studies have assessed outcomes for both primary and revision shoulder instability procedures in this patient population, but there is a paucity of data regarding the outcome of shoulder arthroplasty in EDS patients. The purpose of this study is to evaluate the results and complications of shoulder arthroplasty (SA) performed in a cohort of patients with EDS and compare them to a matched cohort of patients with no EDS.

Methods: Over an 11-year period, 10 patients with EDS were identified at a single institution who underwent primary SA (6 anatomic total shoulder arthroplasties [aTSAs], 4 reverse shoulder arthroplasties [RTSAs]). Shoulders were evaluated at a mean follow-up of 60 months (range 25-97 months). This cohort was matched 1:2 based on age, sex, and year of surgery, with patients who underwent SA for either primary osteoarthritis (OA) for aTSA or cuff tear arthropathy for RTSA. EDS patients had a mean age of 55 years, mean body mass index of 26.1, and were all female. The primary outcome measures were postoperative pain, range of motion, complications, and reoperations.

Results: SA produced similar postoperative pain, range of motion, complications, and reoperations in patients with EDS vs. controls. EDS patients improved pre- to postoperative visual analog scale (VAS) pain score (6.5 to 1.7, P < .001), elevation (96° to 138°, P = .04), and external rotation (36° to 57°, P = .16). Three EDS patients sustained postoperative complications (2 instability and 1 acromial fracture); however, no shoulder was reoperated.

Conclusions: EDS patients undergoing SA can expect outcomes comparable to patients with primary OA or cuff tear arthropathy, with clinically meaningful improvements in pain and range of motion. Although EDS patients had no statistically significant increase in complications when compared to controls, their absolute rate of overall complications (3/10 patients; 30%) and postoperative instability (2/10 patients; 20%) in this small case series was relatively high and should be considered when performing SA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.03.146DOI Listing
April 2021

Revision Reverse Shoulder Arthroplasty for Anatomical Glenoid Component Loosening Was Not Universally Successful: A Detailed Analysis of 127 Consecutive Shoulders.

J Bone Joint Surg Am 2021 May;103(10):879-886

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Glenoid component loosening is a primary cause of failure of anatomical total shoulder arthroplasty (TSA) and is commonly associated with glenoid bone loss. The purpose of the present study was to evaluate the outcome and survival following revision to a reverse total shoulder arthroplasty (RSA) for the treatment of loosening of a polyethylene cemented glenoid component in the setting of failed TSA.

Methods: Between 2010 and 2017, 151 shoulders underwent revision to RSA for the treatment of loosening of an anatomical polyethylene glenoid component. Shoulders with staged reconstruction for the treatment of infection were excluded. One hundred and twenty-seven patients (67 women and 60 men) had a single-stage reconstruction and were available for follow-up. The mean age at the time of surgery was 70 years (range, 41 to 93 years). In all cases, the humeral component was revised and a standard glenoid baseplate was utilized. Bone graft was used at the discretion of the treating surgeon. Medical records and radiographs were reviewed to collect demographic, intraoperative, and postoperative data; to quantify glenoid bone loss; and to determine the radiographic outcome. The mean duration of follow-up was 35 months (range, 24 to 84 months).

Results: Revision to RSA resulted in significant improvements in terms of pain and motion. Sixteen shoulders (13%) underwent revision surgery for the treatment of baseplate loosening. Radiographic baseplate loosening was present in 6 additional shoulders (overall rate of baseplate loosening, 17%). Intraoperative fracture or fragmentation of the greater tuberosity occurred in 30 shoulders (24%). Other reoperations included resection for deep infection (3 shoulders), arthroscopic biopsies for unexplained persistent pain (2 shoulders), humeral tray exchange for dislocation (2 shoulders), revision for humeral loosening (1 shoulder), irrigation and debridement for hematoma (1 shoulder), and internal fixation of periprosthetic fracture (1 shoulder) (overall reoperation rate, 20%). Among shoulders with surviving implants at the time of the most recent follow-up, pain was rated as none or mild in 83 shoulders (65.4%) and the average active elevation and external rotation were 132° and 38°, respectively. With the numbers available, no risk factors for failure could be identified.

Conclusions: Revision RSA for the treatment of loosening of an anatomical polyethylene component was associated with a 17% glenoid mechanical failure rate. Although this procedure resulted in improvements in terms of pain and function, it was not universally successful and thus needs further refinement in order to improve outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.20.00555DOI Listing
May 2021

Sonication improves microbiologic diagnosis of periprosthetic elbow infection.

J Shoulder Elbow Surg 2021 Aug 18;30(8):1741-1749. Epub 2021 Feb 18.

Divisions of Clinical Microbiology and Infectious Diseases, Mayo Clinic, Rochester, MN, USA; Infectious Diseases, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Periprosthetic joint infection (PJI) is a relatively frequent and oftentimes devastating complication after total elbow arthroplasty (TEA). Its microbiologic diagnosis is usually based on periprosthetic tissue culture (hereafter referred to as tissue culture), but the sensitivity of tissue culture is variable. Although implant sonication culture has been shown to be superior to tissue culture for the diagnosis of hip and knee PJI, only a single small study (of fewer than 10 infected implants) has assessed sonication for PJI diagnosis after elbow arthroplasty.

Methods: We retrospectively analyzed 112 sonicate fluid cultures from patients who underwent revision of a TEA at a single institution between 2007 and 2019, comparing results to those of tissue cultures. We excluded patients who had fewer than 2 tissues submitted for culture. Using the Infectious Diseases Society of America guidelines to define PJI, there were 49 infected and 63 non-infected cases. Median ages in the PJI and non-infected groups were 66 and 61 years, respectively. In the non-infected group, 65% were female vs. 63% in the PJI group. We reviewed clinical characteristics and calculated the sensitivity and specificity of tissue compared with sonicate fluid culture. In addition, we compared the sensitivity of tissue culture to the combination of tissue and sonicate fluid culture.

Results: The most common pathogens were coagulase-negative Staphylococcus sp (49%), followed by Staphylococcus aureus (12%). Sensitivity of tissue culture was 63%, and sensitivity of sonicate fluid culture was 76% (P = .109). Specificity of tissue culture was 94% and specificity of sonicate fluid culture was 100%. Sensitivity of sonicate fluid culture in combination with tissue culture was 84% (P = .002 compared to tissue culture alone).

Conclusion: In this study, we found that the combination of sonicate fluid and tissue culture had a greater sensitivity than tissue culture alone for microbiologic diagnosis of PJI after TEA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.01.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319056PMC
August 2021

Primary reverse shoulder arthroplasty in patients with metabolic syndrome is associated with increased rates of deep infection.

J Shoulder Elbow Surg 2021 Sep 8;30(9):2032-2040. Epub 2021 Feb 8.

Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Background: Metabolic syndrome (MetS) is an abnormal physiological condition that has been increasingly identified as a risk factor for complications after orthopedic surgery. Given the lack of information on the effect of MetS in shoulder arthroplasty (SA), this investigation analyzed the rates of postoperative complications and implant survivorship free from reoperation and revision in patients with and without MetS.

Methods: Between 2007 and 2017, data from 4635 adults who underwent a primary SA were collected and classified based on the presence or absence of MetS. MetS was defined as the existence of type 2 diabetes mellitus and a minimum of 2 of the following diagnoses: hyperlipidemia, hypertension, and body mass index ≥ 30 kg/m within 1 year of surgery. Of the 4635 arthroplasties, 714 were performed in patients with MetS (anatomic total shoulder arthroplasty [aTSA] in 289 and reverse shoulder arthroplasty [RSA] in 425) and 3921 were performed in patients without MetS (aTSA in 1736 and RSA in 2185). Demographic characteristics, complications, reoperations, and revision surgery were compared.

Results: At a mean of follow-up of 4.5 ± 2.3 years, 67 MetS patients (9.4%) and 343 non-MetS patients (8.7%) had sustained at least 1 postoperative complication (P = .851). Rotator cuff failure was the most common complication overall, with 84 cases (1.8%) (15 MetS cases [2.1%] and 69 non-MetS cases [1.8%], P = .851), and in both MetS and non-MetS patients, followed by infection, with 68 cases (1.2%) (10 MetS cases [1.4%] and 58 non-MetS cases [1.2%], P = .913). For aTSAs, the most common complication was rotator cuff failure (84 shoulders, 1.8%); for RSAs, the most common complication was periprosthetic fracture (52 shoulders, 1.1%). In RSAs, the rates of deep infection (1.9% vs. 0.7%, P = .04), instability (3.1% vs. 1.5%, P = .04), and deep venous thrombosis or pulmonary embolism (0.5% vs. 0.3%, P = .03) were found to be significantly higher in patients with MetS than in those without MetS. Reoperations were observed in 36 MetS patients (5%) and 170 non-MetS patients (4.3%) (P = .4). Revisions were performed in 30 MetS patients (4.2%) and 127 non-MetS patients (3.2%) (P = .19). The Kaplan-Meier 5-year rate of survivorship free from reoperation, revision, and prosthetic joint infection was equal between groups.

Conclusions: A preoperative diagnosis of MetS in patients undergoing primary SA did not significantly increase the risk of postoperative complications, infection, reoperation, or revision following primary SA. However, in the RSA subgroup, complications were significantly more common in patients with MetS. Individual risk factors may be more appropriate than the umbrella diagnosis of MetS prior to aTSA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.12.025DOI Listing
September 2021

Shoulder Arthroplasty for Patients With Proximal Humeral Paget's Disease.

Orthopedics 2021 Jul-Aug;44(4):e614-e619. Epub 2021 Jul 1.

Poorly controlled Paget's disease leads to excessive blood loss following total hip arthroplasty. The effect in shoulder arthroplasty is unknown. The authors reviewed 3 patients with Paget's disease involving the proximal humerus, comparing them with 17 patients with Paget's disease but no humeral involvement. The 3 patients had an estimated blood loss of 1400 mL, 1100 mL, and 350 mL, compared with an average of 280 mL in the control group. The first 2 cases required 4 units of packed red blood cells intraoperatively, and both were not managed with bisphosphonates. Paget's disease of the humerus leads to more intraoperative blood loss and higher blood transfusion requirements, particularly in cases not managed with bisphosphonates. [. 2021;44(4):e614-e619.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20210201-04DOI Listing
July 2021

How common is fatty infiltration of the teres minor in patients with shoulder pain? A review of 7,367 consecutive MRI scans.

J Exp Orthop 2021 Jan 29;8(1). Epub 2021 Jan 29.

Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.

Purpose: The teres minor is particularly important for activities that require external rotation in abduction in the settings of both rotator cuff tears and reverse shoulder arthroplasty. This study sought to assess the incidence of teres minor fatty infiltration in a large cohort of consecutive patients evaluated with shoulder MRI for shoulder pain and to identify all associated pathologies in an effort to determine the various potential etiologies of teres minor involvement.

Methods: A retrospective review of 7,376 non-contrast shoulder MRI studies performed between 2010 and 2015 were specifically evaluated for teres minor fatty infiltration. Studies were reviewed by two fellowship trained musculoskeletal radiologists. Muscle atrophy was graded on a 3-point scale according to Fuchs and Gerber. The remaining rotator cuff tendons and muscles, biceps tendon, labrum, and joint surfaces were assessed on MRI as well.

Results: In this series, 209 (2.8%) shoulders were noted to have fatty infiltration of the teres minor. The rate of isolated fatty infiltration of the teres minor was 0.4%. Concomitant deltoid muscle atrophy was common, and occurred in 68% of the shoulders with fatty infiltration of the teres minor. Tearing of the teres minor tendon was extremely rare.

Conclusion: Fatty infiltration of the teres minor can occur in isolation, be associated with deltoid muscle atrophy only, or occur in the setting of rotator cuff full tears. Thus, fatty infiltration of the teres minor may be related to a neurologic process or disuse. Further long term longitudinal studies are necessary to be elucidate the etiologies.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40634-021-00325-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846642PMC
January 2021

Analysis of patient characteristics and outcomes related to distance traveled to a tertiary center for primary reverse shoulder arthroplasty.

Arch Orthop Trauma Surg 2021 Jan 28. Epub 2021 Jan 28.

Department of Orthopedic Surgery, Mayo Clinic, Gonda 14, 200 First Street SW, Rochester, 55905, USA.

Introduction: The reasons for referral and travel patterns are lacking for patients undergoing reverse shoulder arthroplasty (RSA). The purpose of this study was to compare comorbidities, surgical time, cost and complications between local and distant primary RSA patients.

Methods: Between 2007 and 2015, 1,666 primary RSAs were performed at our institution. Patients were divided into two cohorts, local patients (from within Olmstead county and surrounding counties, 492 RSAs) and those from a distance (1,174 RSAs).

Results: Local patients were older (74 vs 71 years, p < .001), more likely to have RSA for fracture, had a higher Charlson comorbidity score (3.8 vs 3.2, p < .001) and longer hospital stays (2.0 vs 1.8 days, p < 0.001) compared to referred patients. Referral patients required longer operative times (95 vs 88 min, p = .002), had higher hospitalization costs ($19,101 vs $18,735, p < .001), and had a higher rate of prior surgery (32% vs 24%, p < .001). There were no differences between cohorts regarding complications or need for reoperation.

Conclusions: Patients traveling from a distance to undergo primary RSA had longer operative times and were more likely to have had prior surgery than local patients. This may demonstrate the referral bias seen at large academic centers and should be considered when reviewing RSA outcomes, hospital performance, and calculating insurance reimbursement.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00402-021-03764-9DOI Listing
January 2021

Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly.

J Shoulder Elbow Surg 2021 Jul 20;30(7S):S131-S139. Epub 2021 Jan 20.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: The relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared with TSA. Therefore, it is important to understand the clinical outcomes and rates of revision surgery and secondary rotator cuff tears in elderly patients undergoing TSA.

Methods: Between January 1, 2010, and December 31, 2017, 377 consecutive TSAs were performed for primary GHOA in 340 patients 70 years of age or older. The mean age at surgery was 76.2 years (standard deviation [SD], 4.9). Clinical evaluation included pain, motion, and American Shoulder and Elbow Surgeons score. Radiographs were reviewed for preoperative morphology and postoperative complications. All complications and reoperations were recorded. The average clinical follow-up time was 3.3 years (SD, 2.0). Statistical analyses were performed, and Kaplan-Meier implant survival estimates were calculated. For all analyses, a P value <.05 was considered statistically significant.

Results: The mean pain visual analog scale and American Shoulder and Elbow Surgeons score at the final follow-up were 1.6 (SD, 2.2) and 78.0 (SD, 17.8), respectively. Forward elevation and external rotation increased from 96° (SD, 30°) and 26° (SD, 20°) preoperatively to 160° (SD, 32°) and 64° (SD, 26°) postoperatively (P < .001 for each). The percentage of patients who had internal rotation to L5 or greater increased from 24.8% preoperatively to 71.8% postoperatively (P < .001). Revision surgery was performed in 3 shoulders (0.8%), and the 5-year implant survival estimate was 98.9% (95% confidence interval: 97.3%-100%). There were 3 medical (0.8%), 10 minor surgical (2.7%), and 5 major surgical (1.3%) complications. No shoulder had radiographic evidence of humeral component loosening, whereas 7 (2%) had evidence of some degree of glenoid component loosening. In total, there were 5 secondary rotator cuff tears (1.3%), of which 2 (0.5%) required revision surgery.

Conclusion: Elderly patients with primary GHOA and an intact rotator cuff have excellent clinical and radiographic outcomes after anatomic TSA, with high implant survival rates and a low incidence of secondary rotator cuff tears in the first 5 postoperative years. Age greater than 70 by itself should not be considered an indication for RSA over TSA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.11.030DOI Listing
July 2021

Humeral amputation following total elbow arthroplasty.

Int Orthop 2021 05 15;45(5):1281-1286. Epub 2021 Jan 15.

Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA.

Purpose: Total elbow arthroplasty (TEA) is associated with a relatively high complication rate, and exceptionally catastrophic complications might lead to amputation. The purpose of this study was to determine the incidence and aetiology of amputation performed at our institution in upper extremity limbs with a prior TEA.

Methods: Between 1973 and 2018, 1906 consecutive TEAs were performed at our institution. Upper extremity amputation was performed in seven (0.36%) elbows with five transhumeral amputations and two shoulder disarticulations. The group consisted of five females and two males with a mean age of 64 years (range, 37-80). The index TEA had been performed for rheumatoid arthritis (n = 2), rheumatoid arthritis with acute fracture (n = 2), radiation associated nonunion (n = 2), and metastatic cancer (n = 1). Mean follow-up after amputation was three years (range, 3 months-5 years).

Results: Mean time between amputation and TEA was 5 years (range, 2 months-13 years). The indications for amputation included uncontrolled deep infection in six (86%) elbows and tumor recurrence in one (14%) elbow. Only one elbow (14%) was fitted with a prosthesis. Six (86%) patients died at a mean of three years (range, 3 months-5 years) after amputation.

Conclusion: The results of this study highlight a low incidence of amputation after TEA. Most amputations were the direct result of TEA complications, with infection being the most common cause of amputation. Outcomes after amputation are concerning, with poor overall survival and few patients being fit for a prosthesis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00264-020-04906-1DOI Listing
May 2021

Shoulder arthroplasty in patients with upper extremity lymphedema may result in transient or permanent lymphedema worsening.

Shoulder Elbow 2020 Dec 11;12(1 Suppl):53-60. Epub 2019 Jul 11.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA.

Introduction: Upper extremity lymphedema can complicate mastectomy, lymph node dissection, and radiation. The purpose of this study is to present the outcomes of shoulder arthroplasty in patients with lymphedema.

Methods: The 19 shoulders with a shoulder arthroplasty and lymphedema on the surgical side (6 anatomic, 12 reverse, 1 hemiarthroplasty) were followed for four years (1-10 years). There were 2 males and 17 females; average age was 67.8 (48-86) years. Breast carcinoma was the most common reason for lymphedema (75%). A dedicated lymphedema questionnaire could be completed for 14 shoulders.

Results: Pain improved from moderate or severe preoperatively to no or mild in 18 shoulders. Motion improved in elevation (55° preoperatively, 107° at last follow-up), external rotation (14°, 43°), and internal rotation (sacrum, L5). Complications included an acromion stress fracture with a deep infection (1), deep infection (1), superficial infection (1), and glenoid loosening (1). Lymphedema worsened in nine cases, but worsening was permanent in only four. Currently, lymphedema treatment is being performed by 93% of survey respondents. No patients reported lymphangitis or lymphangiosarcoma.

Conclusion: Shoulder arthroplasty for an upper extremity with lymphedema provides substantial improvements in pain and motion; however, infection is a concerning complication. Fifty percent of the patients will experience worsening of their lymphedema and in 20% worsening may be permanent.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1758573219859473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726181PMC
December 2020

Correlation between hemolytic profile and phylotype of (formerly ) and orthopedic implant infection.

Shoulder Elbow 2020 Dec 9;12(6):390-398. Epub 2019 Aug 9.

Mayo Clinic, Rochester, USA.

Introduction: is a recognized culprit for implant-associated infections, but positive cultures do not always indicate clinically relevant infection. Studies have shown a correlation between the β-hemolytic phenotype of and its infectious capacity, but correlation with genetic phylotype has not been performed in literature. The purpose of this study is to evaluate β-hemolysis phenotype, genetic phylotype, and mid-term clinical outcomes of isolated from orthopedic surgical sites.

Methods: Fifty-four isolates previously obtained from surgical wounds of patients undergoing hip, knee, shoulder, or spine implant removal were re-cultured. There were 21 females and 33 males with an average age of 59 years (range, 18-84). Twenty-four were from clinically infected sites whereas 30 were considered contaminants. De novo β-hemolysis was analyzed and a retrospective chart review was performed to evaluate clinical outcomes at 7.1 years (range, 0.1-12.8).

Results: On agar with 5% rabbit blood, 46% of contaminant and 43% of infectious isolates were hemolytic. Type II phylotype was significantly more nonhemolytic regardless of infectious or contaminant status (p < 0.05). Type 1B correlated with a hemolytic-infectious phenotype and Type 1A with a hemolytic-contaminant phenotype but was not statistically significant.

Conclusion: The β-hemolytic profile of did not correlate with phylotype or clinically relevant orthopedic infection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1758573219865884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689609PMC
December 2020

Humeral stress shielding following cemented endoprosthetic reconstruction: An under-reported complication?

J Surg Oncol 2021 Feb 1;123(2):505-509. Epub 2020 Dec 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: The proximal humerus is a common location for primary and non-primary tumors. Reconstruction of the proximal humerus is commonly performed with an endoprosthesis with low rates of structural failure. The incidence and risk factors for stress shielding are under reported.

Methods: Thirty-nine (19 male, 20 female) patients underwent resection of the proximal humerus and reconstruction with a cemented modular endoprosthesis between 2000 and 2018. The mean resection length was 12 ± 4 cm and was most commonly performed for metastatic disease (n = 26, 67%).

Results: Stress shielding was observed in 9 (23%) patients at a mean of 29 (6-132) months postoperatively. Patients with stress shielding were noted to have shorter intramedullary stem length (87 vs. 107 mm, p < .001), longer extramedullary implant length (16 vs. 14 cm, p = .01) and a higher extramedullary implant to stem length ratio (2.1 vs. 1.1, p < .001). The incidence of stress shielding was higher (p = .003) in patients reconstructed with 75 mm stem (n = 6, 67%) lengths.

Conclusion: Stress shielding of the humerus was associated with the use of shorter stems and long extramedullary implants. The long-term ramifications of stress shielding on implant stability, complications at the time of revision surgery, and overall patient outcomes remain unknown.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26300DOI Listing
February 2021

Incidence of and Risk Factors for Glenohumeral Osteoarthritis After Anterior Shoulder Instability: A US Population-Based Study With Average 15-Year Follow-up.

Orthop J Sports Med 2020 Nov 11;8(11):2325967120962515. Epub 2020 Nov 11.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: The rate of osteoarthritis (OA) in patients with a history of previous anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in cohorts treated nonoperatively and operatively are not well-defined.

Purpose: To determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA in patients younger than 40 years with a known history of ASI.

Study Design: Case-control study; Level of evidence, 3.

Methods: An established, geographically based database was used to identify patients in the United States who were younger than 40 years and were diagnosed with ASI between 1994 and 2014. Patient information, including demographic, imaging, and surgical details, was collected. Comparative analysis was performed between groups with and without OA at final follow-up as well as between patients who underwent surgical and nonsurgical management.

Results: The study population consisted of 154 patients with a mean follow-up of 15.2 years (range, 5.1-29.8 years). The mean age at initial instability event was 20.9 years (95% CI, 19.9-22.0 years). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Multivariate analysis revealed that current or former smokers (odds ratio [OR], 4.3; 95% CI, 1.1-16.5; = .030), hyperlaxity (OR, 10.1; 95% CI, 1.4-72.4; = .020), laborer occupation (OR, 6.1; 95% CI, 1.02-36.1; = .043), body mass index (BMI) (OR, 1.2; 95% CI, 1.03-1.3; = .012), and age at initial instability (OR, 1.1; 95% CI, 1.02-1.2; = .013) as potential independent risk factors when accounting for other demographic and clinical variables.

Conclusion: In a US geographic population of patients younger than 40 years with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographic and clinical data, we noted a potentially increased risk for the development of OA in patients who are current or former smokers, have hyperlaxity, are laborers, have higher BMI, and have increased age at initial instability event. Smoking status, occupation, and BMI are modifiable factors that could potentially decrease risk for the development of symptomatic OA in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967120962515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675883PMC
November 2020

A Potential Theragnostic Regulatory Axis for Arthrofibrosis Involving Adiponectin (ADIPOQ) Receptor 1 and 2 (ADIPOR1 and ADIPOR2), TGFβ1, and Smooth Muscle α-Actin (ACTA2).

J Clin Med 2020 Nov 17;9(11). Epub 2020 Nov 17.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA.

(1) Background: Arthrofibrosis is a common cause of patient debility and dissatisfaction after total knee arthroplasty (TKA). The diversity of molecular pathways involved in arthrofibrosis disease progression suggest that effective treatments for arthrofibrosis may require a multimodal approach to counter the complex cellular mechanisms that direct disease pathogenesis. In this study, we leveraged RNA-seq data to define genes that are suppressed in arthrofibrosis patients and identified adiponectin () as a potential candidate. We hypothesized that signaling pathways activated by ADIPOQ and the cognate receptors ADIPOR1 and ADIPOR2 may prevent fibrosis-related events that contribute to arthrofibrosis. (2) Methods: Therefore, ADIPOR1 and ADIPOR2 were analyzed in a TGFβ1 inducible cell model for human myofibroblastogenesis by both loss- and gain-of-function experiments. (3) Results: Treatment with AdipoRon, which is a small molecule agonist of ADIPOR1 and ADIPOR2, decreased expression of collagens (, , and ) and the myofibroblast marker smooth muscle α-actin (ACTA2) at both mRNA and protein levels in basal and TGFβ1-induced cells. (4) Conclusions: Thus, ADIPOR1 and ADIPOR2 represent potential drug targets that may attenuate the pathogenesis of arthrofibrosis by suppressing TGFβ-dependent induction of myofibroblasts. These findings also suggest that AdipoRon therapy may reduce the development of arthrofibrosis by mediating anti-fibrotic effects in joint capsular tissues.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm9113690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698546PMC
November 2020

Is Allograft Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow a Viable Option for Nonelite Athletes? Outcomes at a Mean of 8 Years.

Orthop J Sports Med 2020 Oct 16;8(10):2325967120959141. Epub 2020 Oct 16.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: The rate of elbow medial ulnar collateral ligament (MUCL) injury and surgery continues to rise steadily. While authors have failed to reach a consensus on the optimal graft or anchor configuration for MUCL reconstruction, the vast majority of the literature is focused on the young, elite athlete population utilizing autograft. These studies may not be as applicable for the "weekend warrior" type of patient or for young kids playing on high school leagues or recreationally without the intent or aspiration to participate at an elite level.

Purpose: To investigate the clinical outcomes and complication rates of MUCL reconstruction utilizing only allograft sources in nonelite athletes.

Study Design: Case series; Level of evidence, 4.

Methods: Patient records were retrospectively analyzed for individuals who underwent allograft MUCL reconstruction at a single institution between 2000 and 2016. A total of 25 patients met inclusion criteria as laborers or nonelite (not collegiate or professional) athletes with a minimum of 2 years of postoperative follow-up. A review of the medical records for the included patients was performed to determine survivorship free of reoperation, complications, and clinical outcomes with use of the Summary Outcome Determination (SOD) and Timmerman-Andrews scores. Statistical analysis included a Wilcoxon rank-sum test to compare continuous variables between groups with an alpha level set at .05 for significance. Subgroup analysis included comparing outcome scores based on the allograft type used.

Results: Twenty-five patients met all inclusion and exclusion criteria. The mean time to follow-up was 91 months (range, 25-195 months), and the mean age at the time of surgery was 25 years (range, 12-65 years). There were no revision operations for recurrent instability. The mean SOD score was 9 (range, 5-10) at the most recent follow-up, and the Timmerman-Andrews scores averaged 97 (range, 80-100). Three patients underwent subsequent surgical procedures for ulnar neuropathy (n = 2) and contracture (n = 1), and 1 patient underwent surgical intervention for combined ulnar neuropathy and contracture.

Conclusion: Allograft MUCL reconstruction in nonelite athletes demonstrates comparable functional scores with many previously reported autograft outcomes in elite athletes. These results may be informative for elbow surgeons who wish to avoid autograft morbidity in common laborers and nonelite athletes with MUCL incompetency.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967120959141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576921PMC
October 2020
-->