Athwal, George S.

Robotic-assisted reverse shoulder arthroplasty has recently entered early limited clinical use, with the goal of improving the execution of preoperative plans and reducing malposition outliers that increase complication rates and health-care costs. This Innovation article reviews the rationale for this technology, explores its potential impact, examines key implementation challenges, and highlights the future directions needed to determine its ultimate value.

Background: Recurrent anterior shoulder instability may lead to capsuloligamentous and bony lesions of the glenoid and humerus. To date, there is no clear consensus on how to best measure anterior glenoid bone loss (GBL) in the setting of recurrent instability. The objective of this study, therefore, was to evaluate the accuracy and reliability of 7 different methods of measuring anterior GBL on three-dimensional models based on computed tomography. Methods: Eight levels of GBL in the anterior and anteroinferior directions were virtually generated in 14 three-dimensional healthy glenoid models. GBL was measured with 7 different methods: based on a height/width ratio (M1), based on surface area within a circle (M2 and M3), based on linear distance within a circle, (M4, M5, and M6), and based on a volume ratio (M7). For each method, the measurement accuracy was assessed by comparing the calculated value with the true amount of generated GBL. The measurement reliability was assessed by computing the score variance and intraclass correlation coefficient. Results: The most accurate (average measurement error of <2% and largest proportion with error <5%) and reliable (ICC >0.96) measurement methods for GBL were M2 (based on surface area) and M5 (based on the linear distance). The average measurement error for the other methods ranged between 3% and 11% for anterior GBL and between 2% and 9% for anteroinferior GBL. For anterior GBL, the measurement increased by an average of 0.5% for each 1% increase in circle radius, leading to an overestimation of GBL with a larger circle diameter Conclusion: The methods for calculating glenoid bone loss performed better for the more common direct anterior bone loss rather than the less common anteroinferior-directed bone loss. Both an area-based method (M2) and linear distance–based method (M5) resulted in accurate and reliable measurements of glenoid bone loss; however, the linear distance–based methods may be easier to perform clinically. The height-width ratio and volume methods were less accurate and reliable. Level of Evidence: Level IV ; case series; diagnostic studies. See Instructions for Authors for a complete description of levels of evidence.

The integration of immersive virtual reality (IVR) in orthopedic surgery offers a platform for surgeon-to-surgeon collaboration. This paper explores a new use case of IVR-based collaboration among orthopedic surgeons, focusing on three key areas: surgical training, procedural planning, and remote peer to peer collaboration. Immersive virtual reality enables surgeons to engage in immersive, interactive environments where complex anatomical structures and surgical techniques can be visualized in three dimensions. This fosters more efficient communication, precise surgical planning, shared learning experiences and an opportunity to enhance 3D visual spatial intelligence. This case study highlights how surgeons in different geographic locations can collaborate, sharing knowledge and expertise in real time without the constraints of physical presence. This connectivity provides a platform for skill acquisition, and the practice of surgical techniques while creating an opportunity for a mentor to educate a remote learner. Moreover, IVR facilitates the rehearsal of a procedure, potentially contributing to improved patient outcomes by reducing errors and enhancing preoperative planning and education. In the context of orthopedic surgery, the ability to virtually simulate surgeries in a collaborative setting represents a novel advancement. IVR also allows for the customization of surgical scenarios, providing surgeons with repeated exposure to common and rare, complex cases, thus broadening their experience base. By supporting a connected surgical community, IVR-based surgeon-to-surgeon collaboration has the potential to create opportunities for educators and learners to connect and learn in a meaningful manner.

Objective: To compare the clinical outcomes of static versus dynamic external fixation for elbow fracture-dislocations with persistent instability after surgical management. Design: Comparative, retrospective review. Setting: Two tertiary referral upper-extremity centers. Patients: Twenty-four elbows requiring external fixation for persistent elbow instability within 90 days of surgical management of an elbow fracture-dislocation. Intervention: Static and dynamic external fixation was used in 16 and 8 patients, respectively, for a median of 39 days (interquartile range, 33–48 days). Main Outcome Measurements: Elbow range of motion, complications, and revision surgeries. Results: Immediately after static and dynamic external fixation removal, there was no difference in elbow extension [33 degrees ± 16 degrees vs. 41 degrees ± 13 degrees, mean difference (MD) 7 degrees, 95% confidence interval (CI) −6 degrees–22 degrees] or flexion (114 degrees ± 35 degrees vs. 118 degrees ± 11 degrees, MD 4 degrees, 95% CI -23 degrees–132 degrees), respectively. At last follow-up, static and dynamic external fixation groups had no difference in elbow extension (27 degrees ± 13 degrees vs. 24 degrees ± 10 degrees, MD -3 degrees, 95% CI –15 degrees–7 degrees) or flexion (129 degrees ± 12 degrees vs. 128 degrees ± 14 degrees, MD -1 degree, 95% CI -13 degrees–10 degrees), respectively. Static and dynamic external fixation groups had no difference in complications [7 (44%) vs. 5 (63%), difference 19%, 95% CI -23%–54%] or revision surgeries [6 (38%) vs. 4 (50%), difference 13%, 95% CI -27%–49%]. Conclusions: No difference in range of motion, complications, and revision surgeries was detected after static versus dynamic external fixation of persistently unstable elbow fracture-dislocations. Due to ease of application, static external fixation is our preferred treatment for these injuries. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Bone loss in shoulder instability is a well-recognized cause of failure after stabilization surgery. Many approaches have been described to address glenoid bone loss, including coracoid transfer. This transfer can be technically difficult and has been associated with high complication rates. An ideal alternative to coracoid transfer would be an autologous source of fresh osteochondral graft with enough surface area to replace significant glenoid bone loss. The distal clavicle potentially provides such a graft source that is readily available and low-cost. Purpose: To evaluate distal clavicular autograft reconstruction for instability-related glenoid bone loss, specifically comparing the width of the clavicular autograft with the width of an ipsilateral coracoid graft as prepared for a Latarjet procedure. Further, we sought to compare the articular cartilage thickness of the distal clavicle graft with that of the native glenoid. Study Design: Controlled laboratory study. Methods: Twenty-seven fresh-frozen cadaver specimens were dissected, and an open distal clavicle excision was performed. The coracoid process in each specimen was prepared as has been described for a classic Latarjet coracoid transfer. In each specimen, the distal clavicle graft was compared with the coracoid graft for size and potential of glenoid articular radius of restoration. The distal clavicle graft was also compared with the native glenoid for cartilage thickness. Results: In all specimens, the distal clavicle grafts provided a greater radius of glenoid restoration than the coracoid grafts ( P < .0001). On average, the clavicular graft was able to reconstruct 44% of the glenoid diameter, compared with 33% for the coracoid graft ( P < .0001). The articular cartilage of the glenoid was significantly thicker (1.4 mm thicker, P < .0001) than that of the distal clavicular autograft (average ± SD, 3.5 ± 0.6 mm vs 2.1 ± 0.8 mm, respectively). When specimens with osteoarthritis were excluded, this difference decreased to 0.97 mm when compared with the clavicular cartilage ( P = .0026). Conclusion: The distal clavicle autograft can restore a significantly greater glenoid bone deficit than the Latarjet procedure and has the additional benefit of restoring articular cartilage to the glenoid. The articular cartilage thickness of the distal clavicle is within 1.4 mm of that of the native glenoid. Clinical Relevance: The distal clavicular autograft may be a suitable option for reconstruction of instability-related glenoid bone loss. This graft provides a structural osteochondral autograft with a broader radius of reconstruction than that of a coracoid graft, is locally available, has minimal donor site morbidity, is anatomic, and provides articular cartilage.

We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture.Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears.Cite this article: Bone Joint J 2014;96-B:224–8.

Purpose Our purpose was to evaluate the distance from the bony edge of the glenoid to the visible (or macroscopic) demarcation at the junction of the labrum and the articular cartilage. Methods Ten fresh‐frozen cadaveric upper extremity specimens were dissected. The shoulder was disarticulated and periarticular structures were removed, leaving the glenoid with the labrum attached. The macroscopic edge of the glenoid was then marked with a drill at the 3‐, 4‐, 5‐, 6‐, 7, 8‐, and 9‐o'clock positions, as defined by a clock face (right) and a reverse clock face (left). Soft tissue and cartilage were then removed, and the distance from the outer edge of the drill hole to the bony rim was measured. Results The mean distance from the bony edge in hourly intervals starting at the 3‐o'clock position anteriorly and extending to the 9‐o'clock position posteriorly was 4.03 mm (range, 2.1 to 5.21 mm; SD, 0.96 mm), 4.2 mm (range, 2.1 to 5.31 mm; SD, 0.97 mm), 4.51 mm (range, 3.1 to 5.2 mm; SD, 0.91 mm), 5.14 mm (range, 3.1 to 7 mm; SD, 1.38 mm), 3.24 mm (range, 1.1 to 5.2 mm; SD, 1.4 mm), 3.78 mm (range, 1 to 6 mm; SD, 1.6 mm), and 4.28 mm (range, 2.1 to 7.3 mm; SD, 1.51 mm), respectively. A trend was noted for significant differences between locations, but this did not reach statistical significance (analysis of variance, P = .086). Conclusions The macroscopic edge of the labrum on the glenoid face does not correspond to the bony edge of the glenoid. The labrum overlaps onto the bony surface of the glenoid from a minimum of 1.6 mm to a maximum of 7.3 mm. Clinical Relevance Our findings provide anatomic data that enhances the arthroscopist's ability to anatomically reconstruct the glenoid labrum.

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem. Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement.

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations.

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.