AAOS: Bloggers examine periprosthetic fracture instructional course lecture, shoulder and elbow presentations

CHICAGO — Some of the most anticipated research in the field of orthopedics is being presented at this year's American Academy of Orthopaedic Surgeons Annual Meeting. To expand our coverage, Orthopedics Today caught up with residents to get their opinions and impressions on this year’s conference.

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Instructional course lectures offer wealth of knowledge

By Roshan P. Shah, MD, JD

It was standing room only in Thursday’s instructional course lecture on periprosthetic fractures. Undoubtedly, most were drawn to having George J. Haidukewych, MD; Kenneth J. Koval MD; Richard F. Kyle, MD; and Frank A. Liporace, MD, in one room sharing their wealth of knowledge. But I worried about another reason for its popularity — maybe folks oversubscribed to the instructional course lecture (ICL) because periprosthetic fractures are on the increase and they are seeing more in their practices.

Roshan P. Shah

The literature has grown quickly on outcomes of periprosthetic fractures in the last several years, and several reports have documented an upward trend in these complications. Two posters shed light on the epidemiology of these fractures and show an earlier occurrence of fracture in noncemented primary and revision total hip arthroplasty as compared to cemented stems.

The ICL was superb, covering both the more common fracture types in the femur as well as rarer fractures of the acetabulum, patella and proximal tibia. These are undoubtedly challenging cases. With the increasing prevalence of periprosthetic fractures and relative shortage of arthroplasty-trained surgeons, courses like these are important for conveying best practices and treatment principles to the wider orthopedic community.

Equally good, the afternoon’s ICL on osteolysis was led by premier faculty, including Charles A. Engh Jr., MD; William J. Maloney, MD; Wayne G. Paprosky, MD; and Neil P. Sheth, MD. They gave an excellent review of the etiology, evaluation, decision making and the surgical treatment principles of hip osteolysis. One of the most challenging scenarios is an asymptomatic patient with significant retroacetabular osteolysis. The decision making between doing a liner exchange vs. a full cup revision is dependent on many factors, Dr. Paprosky said, and many times cannot be determined until the time of surgery.

Finally, health policy fellowship symposium on health care advocacy presented an informative overview of the political process and ways to get involved. John M. Froelich, MD; Stuart L. Weinstein, MD; David Teuscher, MD; and Thomas Bowen, MD, made national politics more accessible and provided a blueprint for becoming successful advocates for orthopedic patients and practices. Dr. Teuscher’s presentation of his experiences in politics, culminating in a major victory in Texas for tort reform was nothing short of fascinating. It is a story I could hear over and over again, and I hope I get the chance to soon.

References:

Abdek MP. Poster #7. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Durrani SK. Poster #166. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Engh CA. Instructional course lecture #361. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Froelich JM. Health care advocacy: Why and how. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Disclosure: Shah has no relevant financial disclosures.

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Prospective randomized trials find no benefit to immobilization after rotator cuff surgery

By Jason E. Hsu, MD

Thursday’s shoulder and elbow sessions included a number of high quality, high level of evidence studies. The morning session was highlighted by two prospective, randomized investigations that addressed the issue of the necessity and length of postoperative immobilization after rotator cuff repair.

Jay D. Keener, MD, and the group from Washington University in St. Louis reported no difference in outcomes after repair of small to medium-sized cuff tears when randomized to two groups — one with early motion and the other with a period of immobilization.

Jason E. Hsu

In the second study, Min Soo Shon, MD, and colleagues followed medium to large-sized cuff tears in two groups randomized to different lengths of immobilization (4 weeks and 8 weeks). This group also found no difference between shorter and longer immobilization in radiographic and clinical outcomes.

Other interesting presentations from the morning session included data from Scott A Rodeo’s group demonstrating that low vitamin D levels may negatively affect early rotator cuff healing. Also, Hyun Min Kim, MD, and his colleagues from Columbia University examined patients that experienced re-tears after rotator cuff repair. They found that when the cuff repair fails, younger, more active patients are more likely to have pain and dysfunction than older patients.

The afternoon sessions shifted to a different topic — reverse total shoulder arthroplasty. Two studies showed encouraging results in using this procedure for the treatment of proximal humerus fractures. First, Pascal Boileaus’ group from France demonstrated that, despite the high mortality rates associated with this elderly patient population, excellent results with low complication rates are observed with reattachment of the tuberosities around the reverse prosthesis. Moderator Joseph P. Iannotti, MD, questioned what indications were used for performing a reverse total shoulder arthroplasty for these proximal humerus fractures. In this particular study, only patients over the age of 70 years received a reverse prosthesis as opposed to an anatomic device.

In the second study, Derek J. Cuff, MD, and Derek Pupello, MD, showed that reverse total shoulder arthroplasty demonstrated superior clinical outcomes and tuberosity healing rates when compared to hemiarthroplasty for fracture. As expected, patients undergoing hemiarthroplasty for fracture that did not have radiographic healing of the tuberosities had particularly poor results. Christian Gerber, MD, said that both these studies report postoperative forward flexion upwards of 140° after reverse total shoulder arthroplasty for fracture. In his experience, good postoperative motion in his healthier patients reaches approximately 110° of forward flexion. This may reflect some differences in methodology of measuring shoulder motion.

T. Bradley Edwards’ group shared a prospective randomized trial hypothesizing that the bony increased offset reverse shoulder arthroplasty (BIO RSA), which utilizes autologous bone graft from the humeral head to lateralize the glenoid component, would decrease scapular notching and improve clinical outcomes compared to a standard Grammont design. Interestingly, this lateral offset design did not result in any radiographic or clinical benefits.

Overall, there were particularly interesting and useful set of podium presentations today. Friday’s sessions include a morning session on shoulder arthritis and anatomic shoulder arthroplasty followed by two afternoon sessions focusing on instability, fractures, shoulder stiffness and elbow disorders.

References:

Alta TD. Paper #511. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Angeline ME. Paper #304. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Cuff DJ. Paper #513. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Keener JD. Paper #31. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Kim HM. Paper #309. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Riley CH. Paper #514. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.
Shon MS. Paper #303. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 19-23, 2013; Chicago.

Disclosure: Hsu has no relevant financial disclosures.