Background: Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. Methods: Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. Results: At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. Conclusions: The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Background: Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years. Purpose: To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear. Study Design: Systematic review. Methods: A systematic review was performed for any articles published before July 2019. The search phrase “labral tear” was used to capture maximum results, followed by keyword inclusion of “SLAP tear” and “biceps tenodesis.” Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined. Results: After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals. Conclusion: BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.
Background: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. Purpose: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports. Results: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02). Conclusion: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.
Background: Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic. Purpose: To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients. Study Design: Cohort study; Level of evidence, 3. Methods: The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827). Results: A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years ( P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period ( P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair ( P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed ( P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) ( P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) ( P < .001). Conclusion: The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.
Purpose of Review Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years. Recent Findings The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. Summary We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.
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