Early radiolucent lines after glenoid component insertion for total shoulder arthroplasty

The clinical importance of the early radiolucent lines after glenoid component insertion for total shoulder arthroplasty remains a topic of debate. Our previous comprehensive review of the literature on the clinical importance of the glenoid component radiolucent lines indicated that these lines do progress. Eventually, these lucencies may lead to symptomatic glenoid component loosening. Some surgeons use pressurized and some unpressurized cementing techniques. In an effort to eliminate those lines some surgeons suggest the use of CO2 also known as carbojet to remove blood from the peg holes on the glenoid bone. Others use packing of the peg holes with a sponge embedded in epinephrine solution. The theory behind the packing is that the epinephrine causes vasoconstriction and minimizes bleeding in the glenoid peg holes allowing the pressurized cement to achieve a better incorporation with the bone at the cement-bone interface.

I personally use an epinephrine solution and a sponge technique for glenoid component bone peg hole preparation. These radiographs below are the x-rays of the first shoulder replacement that I performed after finishing my fellowship. No lucent lines are seen. For further reading I recommend the following study:
http://www.ncbi.nlm.nih.gov/pubmed/22960147

The Doctor the NFL Tried to Silence

League physicians sought to discredit Bennet Omalu’s autopsy study showing widespread brain damage in former Steelers star Mike Webster.

More info:

http://www.wsj.com/articles/the-doctor-the-nfl-tried-to-silence-1448399061

Zion receives bilateral hand transplant. We can learn from this young man and the surgical team who treated him

The field of reconstructive microsurgery is an exciting one. Unfortunately, in the western societies there is very little support for the microsurgeons because poor nerve function and scar tissue formation are the biggest enemies of replantation surgery. Long hours in the operating room, extensive use of resources and high cost are obstacles to the great field of reconstructive surgery. James Urbaniak and Panayotis N Soucacos say: "there is no end to the world of microsurgery". However, how to make a replant, such as a hand or finger or arm, functional remains a big challenge. I think that supporting efforts like the efforts of Dr Scott Levin who was the lead physician of the team that performed the bilateral hand transplantation in Philadelphia is of great importance. I see two exciting scenarios for the future of such surgeries. Tissue engineering or advances in the understanding of graft rejection will make this transplantation surgeries a viable solution to many amputees especially the young children who have a great potential for nerve recovery after end to end nerve repair. We are all excited for what is coming in the near future

SLAP tears and paralabral cysts

Paralabral cysts associated with SLAP lesions are frequent findings on MRI of the shoulder. They can be addressed either with direct decompression or by a repair of the SLAP lesion alone. If there is no history of trauma or the patient is older then clinical followup without surgery is the approach of choice. If they produce pain or weakness and are associated with traumatic labral tears then decompression and repair of the SLAP tear is the debridement of choice. Below please see a case that was approached with decompression using percutaneous arthroscopic technique and an 18G spinal needle. Repair of the SLAP lesion is necessary in these cases for the treatment of pain and avoidance of recurrence of the cyst.

Deja vu. 2011 and 2015

In 2011, we published a study highlighting the need to reconsider using the term of "shoulder impingement" Link

 In August of 2015 the JBJS published a commentary about the classic article published by Charles Neer on acromioplasty. Link

We are glad that the leadership of the Journal of Bone and Joint Surgery adopts our suggestion to stop using the term.

Attached please see the last paragraph from the "Classics documentary"

Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.

Reverse shoulder replacement for irreparable rotator cuff tear with high riding humeral head

Rotator cuff deficiency with a high riding humeral head remains a challenging problem to solve. Shoulder replacement surgery in those individuals is highly technical in terms of correct positioning of implants or soft tissue balancing. Muscle transfers is an alternative solution in the treatment of the rotator cuff deficient shoulder as they can increase the range of motion of shoulder, however they have unpredictable results and they do not address the arthritic pain. If there is arthritis at the glenohumeral joint then is it unlikely that a muscle transfer will provide better quality of life. 

A reverse shoulder replacement can provide solution in cases that the active elevation of the arm is below 90 degrees. Further reading at the JBJS study:  http://dx.doi.org/10.2106/JBJS.K.01206

It must be highlighted though that if the active elevation of the shoulder is at 90 degrees or more then a reverse shoulder replacement may not provide significant benefits.

Below is an example of an elderly person with loss of motion (<90 degrees) and a high riding humeral head treated with a reverse shoulder replacement. The coronal CT shows the high riding humeral head and the sagittal oblique CT shows the significant atrophy of the supraspinatus and the contact of the humerus with the acromion making the repair of the rotator cuff impossible (Goutallier stage 3)

Nature nanotechnology. Detecting bacteria on implants. Timing!

NATURE NANOTECHNOLOGY | ARTICLE

• 
  

A magneto-DNA nanoparticle system for rapid detection and phenotyping of bacteria

• Hyun Jung Chung,
• Cesar M. Castro,
• Hyungsoon Im,
• Hakho Lee
• & Ralph Weissleder

• Nature Nanotechnology
   
  8,
   
  369–375
   
  (2013)
   

One of the most devastating experiences that an orthopaedic surgeon encounters is the infected implant. More importantly, the patient goes through extensive surgery that most of time is of inferior result compared to the first surgery. The socioeconomic cost of the infections in orthopaedics is tremendous. The annual cost of infected revisions to US hospitals is projected to exceed $1.62 billion by 2020.

Often times it is difficult to confirm the presence of bacteria in a wound just by inspecting the color of the fluid, the odor or the macroscopic appearance of the membranes on the implants. There is promising technology being developed that will give us the opportunity to detect an infection in less than 2 hours when currently a standard microbiology lab can give us an answer in 2-3 days and sometimes depending on the micro-organism in 14-21 days.

The magneto-DNA nanoparticle system provides an answer in less than 2 hours. The ideal test would have been similar to a pregnancy test that will give us an answer at the time of surgery. In that scenario orthopaedic surgeons will be able to manage periprosthetic infections more effectively, develop better algorithms and lower the cost of revision arthroplasty care from a financial and social perspective.

http://www.nature.com/nnano/journal/v8/n5/full/nnano.2013.70.html#f5