Graden, Nathan R.

Background: The purpose of this study was to describe, and report the outcomes of, a surgical technique that combines reverse shoulder arthroplasty (RSA) using an allograft-prosthetic composite (APC) with a lower trapezius transfer (LTT) to the infraspinatus of the allograft extended with the inferior capsule. Methods: Between 2019 and 2023, 2 surgeons performed a total of 27 RSAs using an APC in conjunction with an LTT. Once the RSA APC reconstruction had been performed, cuff-capsule allograft tissue was passed posterior to the glenosphere and secured to the harvested lower trapezius. One shoulder was resected for periprosthetic joint infection; the remaining 26 shoulders were followed for a minimum of 2 years (mean, 2.7 years; range, 2 to 5 years). Results: The rate of revision or reoperation for humeral complications was 15% and included secondary bone grafting (2 shoulders), resection for infection (1 shoulder), and internal fixation of a periprosthetic fracture (1 shoulder). Other complications requiring surgery included hematoma treated with evacuation (2 shoulders), dislocation (1 shoulder), and glenosphere disassociation (1 shoulder). Preoperatively, 11 shoulders presented with pseudoparalysis, and the mean active elevation of the remaining 16 shoulders was 43°, with only 1 shoulder demonstrating >90° of active elevation. At the most recent follow-up, 3 shoulders were pseudoparalytic, 11 had <90° of active elevation, 8 had >90° of active elevation, and 3 had active elevation to 90°. The overall mean active elevation of the 25 shoulders that could be assessed was 79°. Preoperatively, only 4 (15%) of the 27 shoulders demonstrated active external rotation past neutral; at the most recent follow-up, 80% of surviving shoulders had active external rotation past neutral. Conclusions: LTT at the time of RSA using an APC has the potential to restore active external rotation in shoulders with proximal humeral bone loss and posterosuperior cuff deficiency. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Frequent pivoting, rotation, and deep hip flexion place football players at high risk for femoroacetabular impingement (FAI), a leading cause of hip pain in this population. Previous studies have primarily focused on professional National Football League athletes undergoing mixed surgical techniques, including labral debridement. Limited data exist on outcomes in younger, amateur players treated with labral repair. Purpose: To report return to sport (RTS) rates and functional outcomes at a minimum 5-year follow-up in primarily active high school and college football players undergoing primary hip arthroscopy with labral repair for FAI. Study Design: Case series, Level of evidence, 4. Methods: All football players who underwent primary hip arthroscopy with labral repair for FAI between 2010 and 2019 were identified from an institutional database. Collected data included descriptive data, radiographic parameters, surgical details, and reoperations. At a minimum 5-year follow-up, RTS outcomes and patient-reported outcome measures (PROMs), such as the Modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS), were evaluated. Results: A total of 36 hips in 27 male athletes (mean age, 18 years; body mass index, 28.1 kg/m 2 ) were included. The majority of athletes competed at the high school (70%) or collegiate level (26%). Mean preoperative radiographic measurements were as follows: lateral center-edge angle, 31.6°; Tönnis angle, 4.1°; and alpha angle, 61.4°. Femoroplasty and acetabuloplasty were performed in 100% and 86% of cases, respectively. Also, 84% of players returned to football, all at the same or higher level than before surgery. At a mean follow-up of 9.8 years, all PROMs improved significantly from baseline ( P < .002). Outcome scores at follow-up were as follows: mHHS 90.5; HOS-Activities of Daily Living, 94.5; HOS-Sports-Specific Subscale, 91.1; and visual analog scale (VAS) pain with use, 2.3/10; VAS pain at rest, 1.3/10; and surgical satisfaction, 8.5/10. No patients required revision surgery. However, 2 patients (7%) underwent reoperations—including 1 for heterotopic ossification excision and 1 for periacetabular osteotomy. Conclusion: American football players who underwent primary hip arthroscopy with labral repair for FAI achieved excellent long-term outcomes, with high RTS rates at the same or higher levels, and improvements in PROMs and patient satisfaction. Despite favorable outcomes, nonmedical factors, such as graduation, may influence RTS in competitive athletes, particularly at the high school and collegiate levels.

Case: A 4-year-old boy with a history of posterior fossa ependymoma resection and radiation treatment developed postlaminectomy kyphosis at the occipito-cervical junction. Cervical radiographs showed 46° kyphosis between C2 and C4. A 3-stage surgical approach was done: halo-gravity traction, anterior C2 to C4 fusion with a fibular allograft, and posterior occiput-C4 instrumented fusion. Halo traction reduced kyphosis by over 50%. At 1-year follow-up, the patient showed stable fixation and successful fusion with modest limitation in cervical motion. Conclusion: The approach effectively corrected the deformity and successfully achieved fusion despite previous radiation treatment and bone deficiency in a very young, skeletally immature patient.

Purpose To compare the cost‐effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum. Methods A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality‐adjusted life‐years (QALYs), and the incremental cost‐effectiveness ratio (ICER). Results Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness‐to‐pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost‐effective strategy in 69% of patients included in the microsimulation model. Conclusions Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost‐effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold. Level of Evidence Level III, economic computer simulation model.