Wagner, Eric R.

AbstractIntroductionThe proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft‐prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies.MethodsA total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10).ResultsReverse reconstructions had improved forward elevation (85° vs. 44°, p < .001) and external rotation (30° vs. 21°; p < .001) versus a hemiarthroplasty. Reverse reconstructions had improved American Shoulder and Elbow Surgeons scores (65 vs. 57; p = .01) and Musculoskeletal Tumor Society 93 scores (72 vs. 63; p < .001) versus hemiarthroplasty. Subluxation of the reconstruction was a common (n = 23, 27%), only occurring in hemiarthroplasty patients (EPR [n = 13, 36%] and APC [n = 10, 59%]).ConclusionThe current series highlights the improved functional outcome in patients undergoing reconstruction with a reverse arthroplasty compared to the traditional hemiarthroplasty. Currently reverse shoulder arthroplasty (APC or EPR) is our preferred methods of reconstruction in this patient population.

AbstractIntroductionTreatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.MethodsData from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.ResultsOf 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).ConclusionOne in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow‐up to minimize readmission.

Background: Surface replacement arthroplasty (SRA) can be used in the treatment of rheumatoid arthritis (RA) affecting the metacarpophalangeal (MCP) joint. The authors of this study sought to investigate the outcomes of MCP SRA in patients with RA. Methods: Retrospective review of medical records and an institutional joint registry were used to gather data on 80 MCP SRAs performed in 27 patients with RA. Data collected included demographics, SRA revisions, reoperations, complications, pain, and MCP arc of motion. Results: The mean postoperative follow-up was 9.5 years (range, 2.1-20.5 years), with all SRAs achieving at least 2 years of follow-up. Thirteen digits (16%) underwent revision arthroplasty, and 29 (36%) required reoperation. The 5-, 10-, 15-, and 20-year rates of survival from implant revision were 95%, 85%, 80%, and 69%, respectively. The 5-, 10-, 15-, and 20-year rates of survival from overall reoperation were 80%, 65%, 55%, and 46%, respectively. Metacarpophalangeal joint arc of motion, grip strength, and pain levels significantly improved following surgery. Conclusions: Metacarpophalangeal SRA can offer benefit to patients with RA for improvement in function and pain. High overall reoperation rates remain concerning; however, most do not involve arthroplasty revision.

This investigation assessed 106 consecutive primary proximal interphalangeal joint arthroplasties performed on border digits: 73 index or 33 little fingers. This was compared with 193 arthroplasties performed in non-border digits: 121 middle or 72 ring fingers. There were 20 proximal interphalangeal joint arthroplasties in the border digits that required revision surgery for pain and stiffness (10 digits), dislocation (six digits), implant fracture (one digit), and infection (three digits). Risk of revision surgery was not associated with border digit. The 5-year implant survival rate for the border digits was 81%. There was no significant difference in implant revision rate or joint dislocations between border and non-border digits. We conclude that proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits. Level of evidence: IV

10531 Background: Osteosarcoma (OS) is a clinically challenging primary malignant bone tumor that has a high rateof local recurrence and metastasis. Disease free survival has been reported to be as low as 19% despite contemporary chemotherapy regimens and surgery. Wnt signaling is known to play a role in osteogenesis and cancer pathogenesis, therefore is a promising target for therapeutic intervention in OS. Secreted Frizzled Related Proteins (sFRPs), Dickkopf-1 (DKK1), and Sclerostin (SOST) are secreted Wnt inhibitor proteins that regulate Wnt signaling in bone. This study investigates the activity of sFRP3, DKK1, and SOST in serum from OS patients with the goal of developing therapeutic Wnt inhibitors and clinically useful biomarkers. Methods: Enzyme linked immunosorbent assayswere used to quantify sFRP3, DKK1 and SOST levels in human serum (n=40 pairs; 20 OS patients, 20 aged matched non-diseased controls). Patients were stratified into 2 age groups: >35 (n=26 pairs) and <30 (n=14 pairs) years of age. Clinical data from the medical records was correlated with experimental results. Using a Wilcoxon signed rank test, a p–value <0.05 was significant. Results: sFRP3 levels were significantly decreased in 55% (22/40) of diseased samples compared to 20% (8/40) of the non-diseased controls (p= 0.007). DKK1 levels were elevated in 40% (16/40) of OS samples compared to 30% (12/40) of the non-diseased controls (p= 0.08). SOST levels were increased in 42.5% (17/40) of diseased samples compared to 32.5% (13/40) of the non-diseased controls (p= 0.38). When stratified by age, the younger patients showed a statistically significant decrease in sFRP3 expression (p<0.001). Serum levels of sFRP3, DKK1, and SOST were not statistically significant between metastatic and non-metastatic OS. Conclusions: Serum sFRP3 levels were significantly decreased in OS patients, a difference that was even more pronounced in the pediatric strata. Since sFRP3 is differentially expressed in patient serum it has potential as a clinical biomarker for initial tumor diagnosis and early detection of recurrence. Decreased sFRP3 expression may be responsible for the up regulation of Wnt signaling in OS. Wnt inhibitors such as sFRP3 have potential as therapeutic agents in OS warranting further investigation.

Objectives: Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or an open Latarjet procedure. Long-term outcomes have shown lower rates of apprehension, recurrent dislocation and operative revision following Latarjet when compared to Bankart repair. However, there is a paucity of studies comparing the short-term post-operative recovery of arthroscopic Bankart versus open Latarjet. The purpose of this study is to evaluate the post-operative recovery following Bankart and the open Latarjet procedure. Methods: The surgical outcomes system (SOS) database (Arthrex Inc., Naples, FL) was used to compare the post-operative recovery outcomes after either a primary or revision arthroscopic Bankart and an open Latarjet procedure. Patients were included who had a minimum of 1 year follow-up. Preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year and 2 year) time points were evaluated. Outcomes measures included Visual Analog Pain Scale (VAS), American Shoulder and Elbow Surgeons (ASES) Shoulder Function Score, ASES Shoulder Index Score, and SANE Score. Overall, 787 patients underwent primary Bankart (518 male, 240 female, 4 not recorded), 36 underwent revision Bankart (24 male, 10 female, 2 not recorded) and 75 underwent an open Latarjet procedure (59 male, 12 female, 4 not recorded). The mean age for primary Bankart, revision Bankart, and open Latarjet was 40.8, 38.6 and 32.8 respectively. Additionally, the average BMI for primary Bankart, revision Bankart, and open Latarjet was 27.2, 28.13, and 25.6, respectively. Results: The postoperative recovery curves are displayed in Figure 1. When compared to primary Bankart, open Latarjet demonstrated significantly lower VAS scores at six weeks (p=0.0272) and at three months (p=0.0094). Medium term outcomes for ASES Shoulder Index Score, ASES Shoulder Function Score, and SANE Score, at 1- and 2-years showed no difference between primary Bankart and Latarjet. For the revision Bankart and open Latarjet procedures, the open Latarjet cohort demonstrated significantly higher ASES Shoulder Index Scores at the 3-months (p= 0.0017), 1-year (p= 0.0021), and 2-years (p= 0.0006) timepoints. Open Latarjet patients also had significantly higher ASES Shoulder Function Scores than revision Bankart at 3-months (p= 0.0162), 1-year (p= 0.0083), and 2-years (p= 0.0013). Revision Bankart repair resulted in significantly higher VAS scores than open Latarjet at 2-weeks (p= 0.0025), 6-weeks (p=0.0114), 3-months (p= 0.0024), 1-year (p= 0.0039), and 2-years (p= 0.0007). Conclusion: When compared to Bankart repair, open Latarjet provides improved pain and functional outcomes during the early recovery phase, 2-weeks, 6-weeks, 3-months, and 6-months, with equivalent medium-term outcomes at 1-2-years. Furthermore, when compared to revision Bankart reconstruction, open Latarjet provides improved ASES Shoulder Index Scores, ASES Shoulder Function Scores and VAS Scores at nearly all timepoints. In the treatment of recurrent anterior glenohumeral instability, open Latarjet is reasonable option in the primary setting and should be favored over Bankart repair for revision cases with improved pain relief and functional scores.

Irreparable rotator cuff tears remain one of the most challenging pathologies faced by shoulder surgeons. In both irreparable anterior (subscapularis) and posterosuperior (supraspinatus and infraspinatus) tears, patients experience marked shoulder dysfunction and pain. In this article, we review the surgical considerations for treating patients with these tears, as well as the tendon transfer options. Irreparable rotator cuff tears are associated with advanced fatty infiltration, tendon retraction, and loss of tendon length. Although there are multiple reconstructive options, most are limited to small series with short-term follow-up. Tendon transfers have emerged as very promising reconstructive options for these patients. When considering the ideal tendon transfer, it is critical to consider the four-tendon transfer principles, as well as the ability of patients to retrain the new transfer to perform a different function. The historical option for posterosuperior tears involved a latissimus dorsi transfer, while the lower trapezius transfer emerged in recent years. The historical transfer for irreparable subscapularis tears was the pectoralis major transfer, while the latissimus dorsi emerged in recent years. Further comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for each of these transfers to treat these difficult pathologies.

Aims Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98.