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   Table of Contents - Current issue
Coverpage
April-June 2016
Volume 10 | Issue 2
Page Nos. 57-93

Online since Wednesday, April 20, 2016

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EDITORIAL  

Arthroplasty of the shoulder joint p. 57
Joe de Beer, Deepak N Bhatia
DOI:10.4103/0973-6042.180716  PMID:27186056
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ORIGINAL ARTICLES Top

Accuracy of patient-specific instrumentation in anatomic and reverse total shoulder arthroplasty p. 59
Richard James Dallalana, Ryan A McMahon, Ben East, Liam Geraghty
DOI:10.4103/0973-6042.180717  PMID:27186057
Purpose: Glenoid component malposition is associated with poor function and early failure of both anatomic and reverse total shoulder arthroplasty. Glenoid positioning is challenging particularly in the setting of bone loss or deformity. Recently, the use of computer assistance has been shown to reduce implantation error. The aim of this study is to evaluate the accuracy of patient-specific instrumentation in cases of anatomic and reverse shoulder replacement in vivo. Methods: Twenty patients underwent total shoulder arthroplasty using a computed tomography (CT)-based patient-specific instrumentation (PSI) system, ten anatomic and ten reverse. Preoperative three-dimensional digital templating of glenoid component position was undertaken and surgery then performed using a custom-made guide. Postoperative CT scans were used to compare final implanted component position to the preoperatively planned position in the same patient. Results: Final component position and orientation closely reflected the preoperatively templated position. Mean deviation in the glenoid version from planned was 1.8° ±1.9° (range, 0.1°-7.3°). Mean deviation in inclination was 1.3° ±1.0° (range, 0.2°-4.5°). Mean deviation in position on the glenoid face was 0.5 ± 0.3 mm (range, 0.0-1.3 mm) in the anteroposterior plane and 0.8 ± 0.5 mm (range, 0.0-1.9 mm) in the superoinferior plane. Actual achieved version was within 7° of neutral in all cases except for one where it was deliberately planned to be outside of this range. Conclusion: PSI in both anatomic and reverse shoulder arthroplasty is highly accurate in guiding glenoid component implantation in vivo. The system can reliably correct bony deformity.
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Observation of initial postoperative radiolucent lines using a modern pegged-glenoid design p. 67
Nathan G Everding, Jonathan C Levy, Nathan T Formaini, Sara Blum, Carlos C Gil, Kevin Verde
DOI:10.4103/0973-6042.180718  PMID:27186058
Purpose: Glenoid component loosening remains a common mode of failure for total shoulder arthroplasty and has inspired improvements in implant design, instrumentation, and surgical technique. The purpose of this manuscript was to evaluate the incidence of radiolucent lines and glenoid seating on initial postoperative radiographs using a modern pegged-glenoid design, instrumentation, and surgical technique. Materials and Methods: We performed a retrospective analysis of a consecutive series of 100 pegged-glenoid total shoulder replacements. In cases of excessive glenoid version, the glenoid was asymmetrically reamed to recreate more normal version. Initial postoperative radiographs were evaluated for the presence of radiolucent lines and completeness of glenoid seating. The preoperative glenoid version measured on axial computed tomography (CT) scans was used to compare differences in version among those with complete and incompletely seated glenoids. Results: The rate of radiolucent lines observed on postoperative radiographs was 0%. Complete glenoid seating (Grade A) was observed in 81 patients (observer 1) and 82 patients (observer 2). Measurements of preoperative CT scans found a higher percentage of abnormal glenoid version for incompletely seated glenoids (47%) than completely seated glenoids (34%) but no significant difference (P = 0.327). The mean preoperative glenoid retroversion for incompletely seated glenoids was 12.1° and 9.1° for completely seated glenoids (P = 0.263). Conclusions: Modern surgical techniques, surgical instrumentation, and peg glenoid design have facilitated the ability to eliminate radiolucent lines on initial postoperative radiographs with high rates of complete seating of glenoid components. Incomplete seating may be related to incomplete correction of glenoid version. Level of Evidence: IV, case series.
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Blood transfusion after total shoulder arthroplasty: Which patients are at high risk? p. 72
Abdurrahman Kandil, Justin W Griffin, Wendy M Novicoff, Stephen F Brockmeier
DOI:10.4103/0973-6042.180719  PMID:27186059
Purpose: There are multiple reported risk factors and a wide range of reported blood transfusion rates for total shoulder arthroplasty (TSA). There are no evidence-based guidelines for blood transfusions in TSA patients. Materials and Methods: We utilized the Nationwide Inpatient Sample to analyze 51,191 patients undergoing TSA between 1998 and 2011. The purpose was to describe the incidence and identify the preoperative factors that are independently associated with blood transfusion after TSA. In addition, we studied the association of blood transfusions with certain variables such as length of stay (LOS), total charges, and payer status. Results: The blood transfusion rate in our study was 6.1%. There was no difference in the rate of blood transfusions over the study period (P < 0.001). In our logistic regression model, significant associations were found with increased age (odds ratio [OR] =1.03), white race (OR = 1.05), higher Charlson-Deyo score (OR = 1.12), presence of ischemic heart disease (OR = 1.24), blood loss anemia (OR = 1.65), female gender (OR = 1.94), presence of coagulation disorders (OR = 2.25), and presence of deficiency anemia (OR = 3.5). Patients receiving a blood transfusion had higher total charges, a longer hospital LOS, and were more likely to be Medicare payers (P < 0.001). Conclusions: Our study found five clinically significant risk factors for blood transfusions for TSA: female gender, ischemic heart disease, deficiency anemia, coagulation disorder, and blood loss anemia. Patients with these risk factors should be considered higher risk for requiring a blood transfusion after TSA and counseled appropriately. Level of Evidence: Level II, retrospective cohort study, prognostic study.
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REVIEW ARTICLE Top

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis: A systematic review p. 78
David M Levy, Geoffrey D Abrams, Joshua D Harris, Bernard R Bach, Gregory P Nicholson, Anthony A Romeo
DOI:10.4103/0973-6042.180720  PMID:27186060
Rotator cuff tears have been reported to be uncommon following total shoulder arthroplasty (TSA). Postoperative rotator cuff tears can lead to pain, proximal humeral migration, and glenoid component loosening. The purpose of this paper was to evaluate the incidence of post-TSA rotator cuff tears or dysfunction in osteoarthritic patients. A systematic review of multiple databases was performed using preferred reporting items for systematic reviews and meta-analyses guidelines. Levels I-IV evidence clinical studies of patients with primary osteoarthritis with a minimum 2-year follow-up were included. Fifteen studies with 1259 patients (1338 shoulders) were selected. Student's t-tests were used with a significant alpha value of 0.05. All patients demonstrated significant improvements in motion and validated clinical outcome scores (P < 0.001). Radiographic humeral head migration was the most commonly reported data point for extrapolation of rotator cuff integrity. After 6.6 ± 3.1 years, 29.9 ± 20.7% of shoulders demonstrated superior humeral head migration and 17.9 ± 14.3% migrated a distance more than 25% of the head. This was associated with an 11.3 ± 7.9% incidence of postoperative superior cuff tears. The incidence of radiographic anterior humeral head migration was 11.9 ± 15.9%, corresponding to a 3.0 ± 13.6% rate of subscapularis tears. We found an overall 1.2 ± 4.5% rate of reoperation for cuff injury. Nearly all studies reported indirect markers of rotator cuff dysfunction, such as radiographic humeral head migration and clinical exam findings. This systematic review suggests that rotator cuff dysfunction following TSA may be more common than previously reported. IV, systematic review of Levels I-IV studies.
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CASE REPORTS Top

Reconstruction of the elbow and forearm for Ewing sarcoma of ulna: A new biological technique p. 85
Ajay Puri, Ashish Gulia, Suman Byregowda, Vishnu Ramanujan
DOI:10.4103/0973-6042.180721  PMID:27186061
Primary bone tumors around the elbow represent <1% of all the skeletal tumors. Surgery with or without adjuvant therapy (radiotherapy, chemotherapy) is the treatment of choice for malignant tumors. Reconstruction of the elbow and forearm in malignant tumors is challenging as it involves a complex interplay between multiple joints which need to be stabilized for the optimal functional outcome. We describe a new technique for the reconstruction of the elbow after resection of a proximal ulna tumor with articular radio-ulnar synostosis with the creation of a single bone forearm. We attempted to achieve a mobile elbow and stable wrist joint with the radio-ulnar union at the proximal articular surface of the ulna resulting in a single bone forearm. The procedure involves an oblique osteotomy preserving the olecranon process (after taking adequate margins based on oncological principles) and its articular cartilage along with the attachment of the triceps tendon. Then the radial head was partially denuded of its cartilage using a burr, leaving cartilage only on the volar side, and then fused to the remnant olecranon. Osteosynthesis was done using compression screw and tension band wiring. The advantages of this procedure are that the mobility at wrist and elbow are retained, it requires minimal hardware and allows for primary closure of the wound.
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Osteochondritis dissecans on the medial aspect of the humeral head p. 89
Yuichiro Mima, Noboru Matsumura, Kiyohisa Ogawa, Takuji Iwamoto, Kensuke Ochi, Kazuki Sato, Yoshiaki Toyama
DOI:10.4103/0973-6042.180722  PMID:27186062
The case of a 29-year-old man who had osteochondritis dissecans on the medial aspect of the humeral head is reported. Repetitive micro-trauma at a low elevated arm position was thought to have induced the osteochondral lesion.
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LETTER TO THE EDITOR Top

Case report of bisphosphonate-associated atypical scapular fracture and brief literature review p. 92
Syed Haque, Radhakant Pandey
DOI:10.4103/0973-6042.180723  PMID:27186063
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