PURPOSE OF REVIEW:The most common complications warranting revision consideration in reverse shoulder arthroplasty (RSA) include instability and its associated causes: infection, periprosthetic fracture, and glenoid baseplate loosening. Management of complications can be challenging and the nuances of treatment are still being elucidated. The focus of this paper is to review the treatment of the failed RSA and discuss evidence-based recommendations for revision. RECENT FINDINGS:The most common complications requiring revision RSA are instability and infection. The causes for instability can be subdivided into three main subcategories: loss of compression, loss of containment, and impingement. Loss of compression is further broken down into 6 subcategories revolving around abnormal prosthesis positioning, undersized prostheses, or intrinsic soft-tissue tension loss leading to instability. Periprosthetic infection can also lead to instability, yet the most appropriate management for infected RSA remains controversial. Restoring stability by maximizing deltoid and soft tissue tension while avoiding impingement revolves around three basic methods: (1) lateralizing and/or upsizing the glenosphere to an inferior position on the glenoid, (2) use of a more constrained polyethylene insert, and (3) distalizing the humerus by increasing the polyethylene thickness and/or the thickness of the humeral tray. Management of periprosthetic joint infection can be performed in one-stage, two-stage, or "three-stage" procedures all showing good outcomes with two-stage procedures being the most commonly performed. However, persistent positive culture with propriobacterium acnes can occur in up to 25% of cases. In order to limit the associated morbidity from failed revision reverse shoulder arthroplasty, continued research on best management of associated complications is warranted.

PURPOSE OF REVIEW: Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty. RECENT FINDINGS: The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive analysis of heterotopic ossification (HO) in pediatric patients, including an in-depth examination of the risk factors associated with this condition, current prophylactic measures, and available management strategies. RECENT FINDINGS: HO is a medical disorder in which bone tissue inexplicably develops in soft tissues such as muscles and tendons. It involves the formation of mature, lamellar bone in extra-skeletal soft tissue, and its formation is influenced by oxygen tension, pH, the availability of micronutrients, and mechanical stimulation. HO has many cellular origins, with the most common theory being multipotent cells in local tissue. The diagnosis of HO is typically made based on exam, radiographs, and CT. Management includes both prophylactic nonsurgical options and surgical resection for severe or recalcitrant cases. The review highlights the incidence, risk factors, and management strategies associated with HO in pediatric patients. HO is a rare condition in children, with severe neurologic injury being the most common cause. Pediatric patients most commonly develop HO following severe neurologic injury, followed by trauma and surgery. Current prophylactic measures, include nonsteroidal anti-inflammatory drugs and radiation therapy though limited literature on their use in the pediatric population exists. For recalcitrant symptomatic cases, wide surgical resection can be considered but has a higher risk profile and associated morbidity. This review highlights the need for further pediatric specific research to inform guidelines and management strategies for this debilitating condition.

Background

An altered tibial position is still present despite anterior cruciate ligament (ACL) reconstruction. It has been demonstrated that an abnormal tibial position after an ACL injury may play a role in subsequent injuries to the meniscus, which can lead to early cartilage degeneration.

Purpose

To determine changes in both the tibial position and the meniscal matrix present before and after ACL reconstruction as well as to evaluate the association between these 2 variables in ACL-injured knees 3 years after reconstruction.

Study design

Cohort study; Level of evidence, 2.

Methods

Bilateral knee magnetic resonance imaging (MRI) of 32 patients with unilateral ACL injuries was performed before reconstruction; 13 control participants also underwent MRI. Follow-up MRI was performed up to 3 years after surgery. Tibial position, internal tibial rotation, and T1ρ and T2 values of the menisci were calculated using an in-house MATLAB program. Student t tests and multiple linear regression were used to compare differences between injured, uninjured, and control knees as well as to assess correlations between the tibial position at 3 years and 3-year changes in quantitative MRI meniscal relaxation values.

Results

The tibial position of injured knees was more anterior than that of uninjured knees at baseline, 6 months, and 1, 2, and 3 years (P < .05 for all). The T1ρ and T2 values of the menisci of injured knees were greater than those of uninjured and control knees in the posterior lateral and posterior medial horns up to 1 and 2 years after surgery, respectively (P < .05 for all). The tibial position at 3 years was associated with increased T2 values from baseline to 3 years in the posterior medial horn (β = 0.397; P = .031) and anterior medial horn (β = 0.360; P = .040).

Conclusion

Results of the current study indicate that there is a persistently altered tibial position after ACL reconstruction. Initial preoperative meniscal abnormalities show prolonged but gradual improvement. Additionally, correlations between the tibial position and changes in the medial meniscal matrix suggest that the tibial position may play a role in the increased susceptibility to medial meniscal tears seen after reconstruction. The development of newer surgical techniques must address a persistently altered tibial position. Quantitative MRI is an effective instrument to evaluate meniscal matrix changes and can serve as an early radiological tool for meniscal injuries.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Background

Recurrent shoulder instability is an orthopedic problem with potentially long-term functional ramifications. Although arthroscopic stabilization has become increasingly utilized over open stabilization, optimal surgical intervention to minimize recurrent instability remains controversial.

Methods

The PearlDiver Mariner database was queried for all cases of open and arthroscopic shoulder stabilization from 2010 to 2019. Utilization trends were aggregated after identifying cohorts of 107,210 and 13,217 patients who respectively underwent arthroscopic or open stabilization using Current Procedural Terminology codes. Subsets from those cohorts with laterality-specific International Classification of Diseases, Tenth Revision codes for shoulder instability were used to evaluate 2-year rates of recurrent instability (presence of shoulder dislocation or revision open or arthroscopic stabilization). Linear regression and chi-squared analysis were used to analyze utilization trends and to compare recurrent instability.

Results

Arthroscopic stabilization comprised 90% of all stabilization procedures with annual utilization continuing to increase into 2019. Latarjet utilization increased from 15% to 42% of all open stabilization procedures while open Bankart repair utilization decreased from 56% to 35%. The rate of recurrent instability was 10.2% after arthroscopic stabilization and 12.3% after open stabilization (P = .01). Rates of redislocation (4.0% vs. 2.6%, P < .01), conversion to shoulder arthroplasty (1.2% vs. 0.4%, P < .01), and revision open stabilization (6.8% vs. 2.3%, P < .01) after index open stabilization were significantly higher than after index arthroscopic stabilization. There was no difference in revision stabilization or dislocation rates between open procedures.

Conclusion

Despite increasing utilization of coracoid transfer, arthroscopic stabilization is still the dominant modality used for surgical treatment of shoulder instability and in our analysis, showed lower 2-year rates of dislocation, revision open stabilization, and conversion to shoulder arthroplasty.

Study design

Prospective cross-sectional survey.

Objective

To determine the perspectives of parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis (AIS) regarding simultaneous surgery and trainee participation.

Summary of background data

Simultaneous ("at the same time") surgery is under scrutiny by the public, government, payers, and the medical community. The objective of this study is to determine the perspectives of parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis. Our goal is to inform the national conversation on this subject with real patient and family voices.

Methods

A survey was prospectively administered to 31 consecutive parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis at a large academic medical center. "Overlapping" was defined as simultaneity during "noncritical" parts of an operation. "Concurrent" was defined as simultaneity that includes "critical" part(s) of an operation. Participants were asked to provide levels of agreement with overlapping and concurrent surgery and anesthesia, as well as with trainee involvement.

Results

On average, respondents "strongly agree" with the need to be informed about overlapping or concurrent surgery. They "disagree" with both overlapping and concurrent scheduling, and "disagree" with trainees operating without direct supervision, even for "noncritical" parts. Informing parents about the presence of a back-up surgeon or research demonstrating safety of simultaneous surgery did not make them agreeable to simultaneous scheduling.

Conclusion

Parents have a strong desire to be informed of simultaneous spinal surgery and anesthesia as part of consent on behalf of their children. Their disagreement with simultaneous surgery, as well as with trainees operating without direct supervision, suggests discordance with current guidelines and practice and should inform the national conversation moving forward.

Level of evidence

N/A.

Background

Prior studies have demonstrated that depression is an independent risk factor for developing a prosthetic joint infection (PJI) after total joint arthroplasty (TJA). To our knowledge, there is no literature examining whether PJI or aseptic failure increases the risk of developing a new mental health diagnosis.

Methods

PearlDiver Patient Database (Colorado Springs, CO) was used to identify 80,826 patients who underwent TJA without a pre-existing diagnosis of depression, anxiety, a stress and/or adjustment disorder, and/or current use of a selective serotonin reuptake inhibitor within the year prior to surgery. The odds of developing a new mental health issue or being prescribed a selective serotonin reuptake inhibitor within 1 year of an uncomplicated TJA was compared to those who developed PJI or mechanical failure within 90 days after TJA as well as to those who subsequently underwent revision surgery within 30 days of either complication using Fisher's exact test and Baptista-Pike.

Results

A total of 6474 (8%) patients were diagnosed with a new mental health issue after TJA. PJI or mechanical failure led to significantly higher odds of new diagnoses with an odds ratio of 1.67 (95% confidence interval = 1.26, 2.22) and 1.57 (1.24, 2.00), respectively. Undergoing revision surgery for PJI or mechanical failure increased the odds of developing a new mental health diagnosis to 2.10 (1.29, 3.42) and 2.24 (1.36, 3.72), respectively. There was no significant difference comparing those who developed PJI vs those who sustained mechanical complications.

Conclusion

Patients who sustain complications after TJA are at increased odds of receiving a new mental health diagnosis, an effect further amplified if revision surgery is required.

Background

Several reports have shown that altered biomechanics after anterior cruciate ligament reconstruction (ACLR) are associated with the development of posttraumatic osteoarthritis. However, it is not fully understood whether altered biomechanics are associated with meniscal changes after ACLR.

Purpose

To investigate changes in gait and landing biomechanics over a 3-year period and their correlation with meniscal matrix alterations present before and after ACLR through use of magnetic resonance T1ρ/T2 mapping, which can allow detection of early meniscal degeneration.

Study design

Cohort study; Level of evidence, 2.

Methods

A total of 36 patients with ACLR and 14 healthy controls were included in this study. All patients underwent magnetic resonance imaging and biomechanical analysis during gait of the injured knee and contralateral knee preoperatively and at 6 months, 1 year, 2 years, and 3 years after ACLR, as well as biomechanical analysis during drop-landing from 6 months to 3 years postoperatively. To evaluate biochemical changes of the mensical matrix, T1ρ/T2 relaxation times of the meniscus were calculated.

Results

Mean T1ρ/T2 values of ACLR knees were significantly higher than values in the contralateral and control knees in the posterior lateral and medial horns up to 1 year after surgery; however, the differences were not seen at 3 years after surgery. The ACLR knee exhibited significantly lower peak knee flexion moment and angle during gait at 6 months compared with baseline and continued to decrease until 3 years. The ACLR knee exhibited significantly lower peak vertical ground-reaction force and peak knee flexion moment and angle during landing at 6 months. However, the differences were no longer present at 3 years. Biomechanics at 6 months had significant correlations with changes of mean T1ρ/T2 values in the medial posterior horn from 6 months to 3 years after ACLR.

Conclusion

Although mean T1ρ/T2 values of meniscus seen before ACLR improved after 3 years, approximately 30% of patients with ACLR did not show decreases from 6 months to 3 years. Patients with abnormal lower limb kinetics of the ACLR knee at 6 months showed less recovery in the medial posterior horn from 6 months to 3 years, suggesting that biomechanical parameters during the early stage of recovery might be potential biomarkers for predicting persistent medial meniscal abnormality after ACLR.