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Background: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport.Questions/purposes: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season?Methods: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes.Results: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football.Conclusion: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers.Level Of Evidence: Level IV, prognostic study. [ABSTRACT FROM AUTHOR]

Background: Bone loss in patients undergoing revision THA poses a considerable challenge for orthopaedic surgeons. Often, to achieve better fixation in remaining bone, larger diameter acetabular components and reaming superiorly may be necessary. However, this is likely to raise the hip center of rotation, which may lead to altered biomechanics, specifically, insufficiency of the abductor muscles, altered gait, and increased risk of dislocation from impingement. More recently, a newer acetabular shell has been designed to more closely replicate the native hip center of rotation in these circumstances while maintaining adequate fixation.Questions/purposes: The purpose of this study was to compare the radiographic parameters of this newer design with conventional hemispheric cups in revision THA. Specifically, we assessed the differences in (1) vertical center of rotation (COR) displacement and (2) horizontal COR displacement.Methods: Between January 2016 and April 2016, five reconstructive surgeons at five institutions utilized a newer highly porous acetabular shell designed with peripheral screw holes and vertically eccentric COR to allow for restoration of center of hip rotation in revision THA. We included all patients who received this device. During this time, the general indications at these sites for using the new device included Paprosky Stage IIA, IIB, IIC, or IIIA acetabular defects. This yielded 29 patients who were subsequently matched (one to two) by cup size and sex to a cohort who underwent revision THA with conventional hemispheric cups between January 2015 and May 2016. To determine hip COR, radiographic measurements were performed. A circle contiguous to the acetabulum was drawn and the center was determined as the hip COR. All measurements were made from the interteardrop line for both the revised and native hips. A line through the teardrops was used for all horizontal measurements. Center position adjustments were made based on the manufacturer-specified values. Comparisons were performed using chi-square tests for categorical and t-tests for continuous variables. There was no difference in the severity of bone loss before the revision in the groups, as evidenced by Paprosky staging of preoperative radiographs.Results: The mean vertical COR displacement was smaller in patients who had the novel cup (3.5 mm; range, -12 to 15 mm; mean difference, -7.3 mm; 95% confidence interval [CI], -13.2 to -1.5) as compared with those who had the conventional cup (10.5 mm; range, -4 to 50 mm; mean difference, 7.3 mm; 95% CI, -12.5 to -2.2; p = 0.003). There was no difference in mean horizontal displacement between the two groups (-0.06 ± 6.1 versus 1.7 ± 7.1; mean difference, -1.8; p = 0.903).Conclusions: Although hip COR was improved based on radiographic measurements with the use of this novel acetabular design, and although this may improve hip biomechanics, more studies are required before its widespread adoption for revision cases of this nature can be recommended. Both implant costs and the risks associated with using a new design in practice will have to be justified by studies that evaluate fixation, clinical function and implant survival, and patient-reported outcome scores, all of which were beyond the scope of this preliminary report.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Polyethylene liner dissociation is a rare but catastrophic event in total hip arthroplasty (THA), and certain implant designs are known to be at greater risk. Although the DePuy Pinnacle (Warsaw, IN, USA) modular acetabular construct has an excellent record of fixation and wear, an unexpectedly high number of liner dissociations has been noted.Questions/purposes: The purposes of this study were (1) to characterize the clinical parameters observed in a large group of patients who have experienced liner dissociations with the DePuy Pinnacle acetabular component; (2) to describe the radiographic findings in this group of patients; and (3) to calculate a minimum frequency of this complication.Methods: Since 2001, 23 patients with previously well-functioning THAs presented with sudden atraumatic polyethylene liner dissociation at four separate institutions. These THAs were performed between 2001 and 2013. Eight different arthroplasty specialists had performed the index hip arthroplasties using the DePuy Pinnacle acetabular component with a polyethylene liner. Polyethylene failures were evaluated for liner type and radiographic cup position. For three of the surgeons who contributed cases, institutional registries allowed the calculation of the number of components of this type that they used during the period in question, which provided a conservative estimate of the frequency of this type of failure.Results: All 23 liner failures occurred atraumatically in previously asymptomatic THAs at a mean of 48 months (range, 3-138 months). Patients characteristically reported a new and sudden onset of discomfort with audible, reproducible squeaking. Surgical inspection of dissociated liners demonstrated displacement of polyethylene with shearing of the peripheral locking tabs. Radiographic evaluation demonstrated that 14 cups were well positioned and nine cups were malpositioned outside the so-called safe zone. Conservative estimates of the frequency of this complication from the three surgeons' practices whose institutional registries allowed calculation of the lowest possible frequency were 0.32% (six of 1888), 0.77% (three of 391), and 0.82% (three of 367).Conclusions: With this report of 23 additional liner dissociations, we suggest that surgeons should be aware of the problem and take extra precautions when using this implant to ensure locking mechanism integrity at the time of surgery. We caution that the frequency of liner dissociation may be higher than previously reported.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Hard-on-hard bearings for total hip arthroplasty continue to warrant analysis even though crosslinked polyethylene is performing very well. Ceramic-on-metal (CoM) has low in vitro wear and did well in an early clinical trial. We report on a prospective, randomized, multicenter investigational device trial comparing CoM with metal-on-metal (MoM).Questions/purposes: (1) Is there a difference in the number or type of revisions comparing CoM with MoM? (2) Are cobalt and chromium metal levels different for CoM and MoM THA?Methods: Between August 2005 and October 2006, of 1015 patients screened, 390 patients were enrolled at 11 centers and randomized to 194 CoM and 196 MoM bearings. There was no difference in the preoperative patient demographics between the study groups. Mean followup was 50 months (range, 22-75 months). Seventy-two patients from two centers had metal level analysis.Results: With the numbers available, there was no difference in the proportion of patients undergoing revisions between the MoM and the CoM cohorts (MOM: 3% [six of 196]; COM: 1.5% [three of 194]; p = 0.50). Four MoM revisions were unrelated to the bearing surface. Two had bearing surface-related reoperations, one for an aseptic lymphocyte-dominated vasculitis-associated lesion and one for elevated metal levels with acetabular malposition. None of the CoM revisions were related to the bearing surface. The metal level analysis revealed that in contrast to the CoM, the MoM bearing group had increasing values of erythrocyte and serum cobalt from 1 to 5 years (CoM erythrocyte 0.45-0.55 ppb, p = 0.11 and CoM serum 0.88-0.85, p = 0.55, and MoM erythrocyte 0.32-0.51 ppb, p < 0.01 and MoM serum 0.65-1.01 ppb, p < 0.01). In addition, the MoM cobalt levels in erythrocytes and serum at 5 years were more variable than at 1 year (erythrocyte interquartile range [IQR], 0.26-0.44 to 0.31-1.21 ppb and serum IQR, 0.42-0.80 to 0.64-2.20 ppb, p < 0.02 for both).Conclusions: Although both bearings performed well at short-term followup, the CoM bearing group had no wear-related revisions and maintained consistently low metal levels. The MoM cobalt elevations may be important considering recent reports of taper corrosion. This CoM bearing was approved by the FDA but withdrawn from the market because of low sales. If it were available, the authors would not use CoM until long-term data were available. The bearing would have to outperform crosslinked polyethylene because it is unlikely that CoM metal levels will return to normal.Level Of Evidence: Level I, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Modular revision femoral components allow the surgeon to make more precise intraoperative adjustments in anteversion and sizing, which may afford lower dislocation rates and improved osseointegration, but may not offer distinct advantages when compared with less expensive monoblock revision stems.Questions/purposes: We compared modular and monoblock femoral components for revision of Paprosky Type I to IIIA femoral defects to determine (1) survivorship of the stems; and (2) complications denoted as intraoperative fracture, dislocation, or failure of osseointegration.Methods: Between 2004 and 2010, participating surgeons at three centers revised 416 total hip arthroplasties (THAs) with Paprosky Type I to IIIA femoral defects. Of those with minimum 2-year followup (343 THAs, mean followup 51 ± 13 months), 150 (44%) were treated with modular stems and 193 (56%) were treated with monoblock, cylindrical, fully porous-coated stems. During this time, modular stems were generally chosen when there was remodeling of the proximal femur into retroversion and/or larger canal diameters (usually > 18 mm). A total of 27 patients died (6%) with stems intact before 2 years, 46 THAs (13%) were lost to followup before 2 years for reasons other than death, and there was no differential loss to followup between the study groups. The modular stems included 101 with a cylindrical distal geometry (67%) and 49 with a tapered geometry (33%). Mean age (64 versus 68 years), percentage of women (53% versus 47%), and body mass index (31 versus 30 kg/m(2)) were not different between the two cohorts, whereas there was trend toward a slightly greater case complexity in the modular group (55% versus 65% Type 3a femoral defects, p = 0.06). Kaplan-Meier survivorship was calculated for the endpoint of aseptic revision. Proportions of complications in each cohort (dislocation, intraoperative fracture, and failure of osseointegration) were compared.Results: Femoral component rerevision for any reason (including infection) was greater (OR, 2.01; 95% CI, 1.63-2.57; p = 0.03) in the monoblock group (27 of 193 [14%]) compared with the modular cohort (10 of 150 [7%]). Femoral component survival free from aseptic rerevision was greater in the modular group with 91% survival (95% CI, 89%-95%) at 9 years compared with 86% survival (95% CI, 83%-88%) for the monoblock group in the same timeframe. There was no difference in the proportion of mechanically relevant aseptic complications (30 of 193 [16%] in the monoblock group versus 34 of 150 [23%] in the modular group, p = 0.10; OR, 1.47; 95% CI, 0.86-2.53). There were more intraoperative fractures in the modular group (17 of 150 [11%] versus nine of 193 [5%]; OR, 2.2; 95% CI, 1.68-2.73; p = 0.02). There were no differences in the proportions of dislocation (13 of 193 [7%] monoblock versus 14 of 150 [9%] modular; OR, 0.96; 95% CI, 0.67-1.16; p = 0.48) or failure of osseointegration (eight of 193 [4%] monoblock versus three of 150 [2%] modular; OR, 1.92; 95% CI, 0.88-2.84; p = 0.19) between the two groups with the number of hips available for study.Conclusions: Although rerevisions were less common in patients treated with modular stems, aseptic complications such as intraoperative fractures were more common in that group, and the sample was too small to evaluate corrosion-related or fatigue concerns associated with modularity. We cannot therefore conclude from this that one design is superior to the other. Larger studies and pooled analyses will need to be performed to answer this question, but we believe modularity should be avoided in more straightforward cases if possible.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Adverse local tissue reactions (ALTRs) around hip arthroplasties are an important reason for failure of metal-on-metal (MoM) hip implants. Little is known about capsular dehiscence patterns as ALTRs decompress from the hip into the surrounding tissue planes; these patterns may also influence the onset and severity of patient symptoms.Questions/purposes: Through a multicenter study approach, we asked: (1) Is ALTR location related to the surgical approach used for arthroplasty in patients who underwent hip arthroplasty (resurfacing or THA) with a single, recalled hip arthroplasty system? (2) Do ALTR severity and location affect patient-reported outcomes in these patients? (3) Is ALTR severity different between patients who received the resurfacing version of this component (Articular Surface Replacement [ASR]) and those who received the THA implant in this system (ASR XL)?Methods: In a multicenter prospective study of patients who had undergone surgery with use of the ASR and ASR XL hip system (DePuy Orthopaedics, Warsaw, IN, USA), 288 patients (333 hips) from two centers had a metal artifact reduction sequence MRI of the hip performed at a mean time of 6 years postsurgery. Procedures included 166 hips (50%) with ASR resurfacing and 167 hips (50%) with ASR XL THA performed between 2004 and 2010. One hundred twenty-nine hips (39%) had been operated on using a direct lateral approach and 204 using a posterior approach (61%). The EQ-5D, Harris hip score, UCLA activity score, and visual analog scale pain score were obtained for each patient. ALTRs were classified using the Anderson ALTR grading system, and the location, synovial thickness, and diameter of the ATLRs were assessed. The relationship between ALTR location and surgical approach as well as for ALTR severity and patient-reported outcomes were evaluated, and logistic regression was used to identify predictors for moderate-to-severe ALTRs.Results: Moderate or severe ALTRs were identified in 79 hips (24%); 41 of these hips had been operated on using the direct lateral approach and 38 using the posterior approach. In patients in whom the lateral approach was used, 83% had an anterior ALTR. Similarly, 71% of patients in the posterior approach group had posterior ALTRs. There were no differences in patient-reported outcome measures between patients with moderate-to-severe ALTRs and those with no ALTR findings on MRI (p > 0.09). Use of ASR XL was an independent risk factor for moderate-to-severe ALTRs (odds ratio, 2.8; 95% confidence interval, 1.4-5.5 p = 0.004) and patients with ASR XL also had a thicker synovium (median ASR XL = 3.6 mm [1.2-10.6 mm], median ASR = 2.6 mm [1.2-10.7 mm], p < 0.001) and larger maximal ALTR diameter (median ASR XL = 47.6 mm [14-109.70 mm], median ASR = 38.4 [17.2-118.0 mm], p = 0.02) than patients treated with ASR.Conclusions: The location of ALTRs can be predicted based on the previous surgical approach to the hip. Patients with ASR XL are more likely to develop moderate-to-severe ALTRs compared with ASR patients. An extensive range of patient-reported outcome measures may not identify all patients with ALTRs further supporting the use of MRI as a screening measure for ALTRs.Level Of Evidence: Level II, therapeutic study. [ABSTRACT FROM AUTHOR]