JAAOS, Volume 26, No. 21

Arthroscopic Management of Glenohumeral Arthritis: A Joint Preservation Approach

Treatment of young, active patients with primary glenohumeral osteoarthritis (GHOA) is challenging because shoulder arthroplasty may not be ideal in this population. In the past two decades, joint-preserving arthroscopic management options for GHOA, including débridement, have been used to treat different pathologies related to GHOA to reduce pain, to improve function, and to delay or even avoid arthroplasty. Key aspects of comprehensively addressing GHOA arthroscopically include chondroplasty, synovectomy, loose body removal, humeral osteoplasty with excision of the goat’s beard osteophyte, capsular release, subacromial and subcoracoid decompression, axillary nerve decompression, and biceps tenodesis. Although data are still emerging, clinical studies report that an arthroscopic approach to glenohumeral arthritis using these various procedures reduces pain, improves function, and improves clinical outcome scores in the short- to mid-term follow-up period. Additional high-level studies are warranted to evaluate long-term outcomes and durability following this procedure.

      • Subspecialty:
      • Shoulder and Elbow

    Chronic Achilles Ruptures: Reconstructive Options

    Achilles tendon ruptures, if neglected or identified late, lead to impairments in function and gait. Surgical reconstruction is typically required to restore the resting length and tension to the gastrocnemius-soleus complex. A variety of reconstructive options have been described, depending on several factors, including chronicity, residual gap size, remaining tissue quality and vascularity, location of tendon rupture or deficiency, and patient-specific factors. Despite the many surgical options described from local soft-tissue rearrangements and tendon transfers, to the use of allograft tissue and synthetic material augmentation, there is understandably a paucity of evidence-based guidelines available to direct surgeons in the optimal procedure for each patient-specific situation. Reconstructive options for the patient with a chronic Achilles rupture are detailed and reviewed here, to serve as a framework for the treating surgeon in these complex cases.

        • Subspecialty:
        • Foot and Ankle

      Diagnosis and Management of Ipsilateral Femoral Neck and Shaft Fractures

      Ipsilateral femoral neck and shaft fractures typically occur as a result of high-energy trauma in young adults. Up to 9% of femoral shaft fractures will have an associated femoral neck fracture. Awareness of this association and the use of a protocolized approach to diagnosis and management can help prevent missed injuries and the associated complications of displacement, nonunion, and osteonecrosis. The femoral neck fracture is often vertically oriented and either nondisplaced or minimally displaced, and thus, these fractures are frequently missed in the initial evaluation. Fixation of these combined injury patterns is challenging, and multiple treatment options exist. Treatment goals should include anatomic reduction and adequate fixation of the femoral neck fracture, as well as restoration of the length, alignment, and rotation of the femoral shaft fracture.

          • Subspecialty:
          • Trauma

          • Adult Reconstruction

        Complications After Pelvic Arteriography in Patients With Pelvic Ring Disruptions

        Introduction: Pelvic angiography with transcatheter arterial embolization (TAE) is an established intervention for management of pelvic arterial hemorrhage. This study analyzes complication rates after angiography among patients with pelvic trauma treated in the context of a multidisciplinary institutional pelvic fracture protocol.

        Methods: Retrospective analysis of prospectively collected data was conducted. Demographics, fracture type, embolization (ie, unilateral versus bilateral and selective versus nonselective), and complications (ie, pseudoaneurysm, renal failure, soft-tissue necrosis/infection, and anaphylactic reactions) were noted.

        Results: Eighty-one patients with pelvic ring injuries underwent angiography from 2009 to 2013. Complications among 41 patients who underwent angiography with TAE were compared with a control group of 40 patients who underwent angiography without TAE. Eight of 41 patients with TAE had complications (19.5%) compared with 3 of 40 (7.5%) in the control group (P = 0.19). The overall complication rate was 13.6%.

        Conclusion: The use of angiography with TAE as part of an institutional pelvic fracture protocol involves an acceptable rate of complications.

        Level of Evidence: III

            • Subspecialty:
            • Adult Reconstruction

          Incidence of Nerve Injury After Hip Arthroscopy

          Introduction: Hip arthroscopy is a commonly performed procedure that carries a notable risk of nerve injury secondary to port placement and the use of axial traction. Sensory neurapraxia of the pudendal nerve and the lateral femoral cutaneous nerve is most common; however, sexual dysfunction and sciatic nerve injury has also been reported. Reported incidence of nerve injury ranges between 1.4% and 5% in the literature, but much of these data are based on unsolicited patient concerns. This study aimed to determine the true rate of nerve injury among this patient population through administration of a validated survey at multiple time points.

          Methods: A prospective study of all patients undergoing hip arthroscopy requiring traction by a single surgeon at our institution was performed. These cases were the first 100 hip arthroscopies performed in practice by the surgeon. Before surgery, all patients were asked about the presence of neuropathic symptoms including sexual dysfunction through administration of a validated questionnaire. The same questionnaire was then administered at several time points postoperatively: on the day of surgery, on postoperative day 2, at the first follow-up visit, and if symptoms persisted, then at each follow-up appointment until resolution of the symptoms. Overall incidence of nerve injury was then calculated. Subgroup analyses were performed to investigate whether traction time, sex, body mass index (BMI), or technically demanding surgical skills affected the incidence.

          Results: This study included a total of 100 patients with an average age of 29 (13 to 62) years and an average BMI of 25. Nerve injury was seen in 13 patients with an incidence of 13%. Specific nerves injured included the pudendal (9), lateral femoral cutaneous (2), sciatic (1), and superficial peroneal nerves (1). Subgroup analysis did not demonstrate a notable association between the risk of nerve injury and increased traction time, sex, or increased BMI. The technically demanding surgical skills was associated with a notable decrease in the traction time, but no notable difference in the risk of nerve injury was observed. Most nerve injuries resolved within 2 weeks (8 of 13), and all cases of nerve injury resolved within 9 months.

          Discussion and Conclusions: The incidence of nerve injury after hip arthroscopy may be markedly higher than previously reported; however, resolution seems to occur as previously found in the literature. Patients should be educated regarding the risk of nerve injury during this procedure.

          Level of Evidence: Level IV

              • Subspecialty:
              • Adult Reconstruction

            Disparities in Total Hip Arthroplasty Outcomes: Census Tract Data Show Interactions Between Race and Community Deprivation

            Introduction: Socioeconomic factors such as poverty may mediate racial disparities in health outcomes after total hip arthroplasty (THA) and confound analyses of differences between blacks and whites.

            Methods: Using a large institutional THA registry, we built models incorporating individual and census tract data and analyzed interactions between race and percent of population with Medicaid coverage and its association with 2-year patient-reported outcomes.

            Results: Black patients undergoing THA had worse baseline and 2-year pain and function scores compared with whites. We observed strong positive correlations between census tract Medicaid coverage and percent living below poverty (rho = 0.69; P < 0.001). Disparities in 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function were magnified in communities with high census tract Medicaid coverage. For blacks in these communities, 2-year WOMAC function scores were predicted to be −5.54 points lower (80.42 versus 85.96) compared with blacks in less deprived communities, a difference not observed among whites.

            Conclusion: WOMAC pain and function 2 years after THA are similar among blacks and whites in communities with little deprivation (low percent census tract Medicaid coverage). WOMAC function at 2 years is worse among blacks in areas of higher deprivation but is not seen among whites.

            Level of Evidence: Level II - Cohort Study

                • Subspecialty:
                • Adult Reconstruction