Claxton-Hepburn Medical Center

Subcritical bone has been shown to result in a higher rate of recurrent instability and inferior outcomes after an arthroscopic soft tissue Bankart procedure alone. The ideal surgery for patients with subcritical bone loss remains controversial, with options including arthroscopic Bankart alone, Bankart plus Remplissage (BRR), open Bankart, or a bone transfer procedure. The purpose of this study is to compare the outcomes between the arthroscopic BRR with an open Latarjet for the treatment of anterior shoulder instability in patients with glenoid bone loss (GBL) from 13.5% to 24% in an active-duty military population. It was hypothesized that there will be no difference in recurrence rate or patient-reported outcomes between the 2 procedures. Cohort study; Level of evidence, 3. A retrospective matched-cohort comparison of patients who underwent anterior glenohumeral instability procedures with subcritical bone loss was performed. Inclusion criteria included symptomatic anterior shoulder instability, subcritical GBL (13.5% to 24%), recurrent instability with ≥2 instability episodes, surgical treatment with arthroscopic BRR or open Latarjet, and minimum follow-up of 2 years. Outcomes assessed included recurrent instability (defined as postoperative dislocation or subjective subluxation), military physical restrictions, Western Ontario Shoulder Instability Index (WOSI) score, and Single Assessment Numeric Evaluation (SANE) score. In total, 50 patients were included, 25 of whom underwent an arthroscopic BRR and 25 patients who were treated with an open Latarjet. Mean bone loss was 16.1% and 19.3%, respectively. Five patients experienced recurrent instability, 3 in the arthroscopic BRR group and 2 in the open Latarjet group (P = .64). Mean postoperative SANE score for the arthroscopic BRR group was 81.6% and open Latarjet group was 84.2% (P = .42). Mean postoperative WOSI score for the arthroscopic BRR group was 64.6% and open Latarjet group was 67.9% (P = .44). There was no difference in the number of patients placed on permanent military physical restriction in the arthroscopic BRR group (n = 2) compared with open Latarjet (n = 3) (P = .64). In our small cohort of active-duty military patients with subcritical GBL, there was no difference in recurrent instability between arthroscopic BRR compared with open Latarjet. Additionally, there was no significant difference in postoperative SANE or WOSI scores, complications, or the number of patients placed on permanent military restriction.

Active-duty military service members experience posterior glenohumeral instability at a rate that far outpaces that of nonmilitary populations. While the outcomes after primary posterior labral repair (PLR) in this population are promising, the outcomes after revision procedures remain poorly described. To report midterm outcomes after revision PLR in a population of active-duty military patients. Case series; Level of evidence, 4. Patients who underwent revision PLR from January 2011 through December 2018 by the senior surgeon with a minimum of 5 years of follow-up were deemed eligible for inclusion. Preoperative and postoperative outcome scores for the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and the Rowe instability score as well as the rates of return to active duty and sports and the rate of recurrent instability were collected and pooled for analysis. Overall, 21 patients with a mean follow-up of 77.95 ± 39.54 months met inclusion criteria and were available for analysis. At midterm follow-up, patients who underwent revision PLR experienced significantly improved VAS (from 7.3 ± 1.8 to 2.9 ± 2.4), ASES (from 49.5 ± 12.6 to 79.7 ± 16.7), SANE (from 45.0 ± 14.8 to 80.2 ± 20.3), and Rowe (from 37.6 ± 9.4 to 79.4 ± 24.7) scores. Over 80% of patients also achieved the minimal clinically important difference for these outcome measures; however, only 52% to 62% of patients achieved the Patient Acceptable Symptom State. The return-to-sport rate was 66.67%, and the return to active-duty rate was 80.95%. While patients who underwent revision PLR experienced improvements in outcomes and a decrease in pain on average, they exhibited rates of return to active-duty and sports that lagged behind those demonstrated in a previous cohort that underwent a primary procedure. Furthermore, the achievement of clinically significant outcomes after revision PLR was less consistent compared with that after primary PLR.

While glenoid bone loss (GBL) after anterior shoulder instability correlates with poor functional outcomes, the specific effects of GBL in posterior and combined-type shoulder instability remain poorly characterized, especially in a high-risk military population. The purpose of this study was to compare GBL between unidirectional anterior or posterior instability versus combined-type instability in active-duty servicemembers. It was hypothesized that total GBL and GBL in the direction of instability would be greater in those with combined-type instability compared with unidirectional instability. Cross-sectional study; Level of evidence, 3. Active-duty servicemembers who underwent shoulder stabilization surgery between January 2010 and December 2019 were eligible for inclusion. Patients with multidirectional instability, concomitant rotator cuff tears, osteochondritis dissecans of the glenoid or humeral head, superior labral anterior-posterior tears, biceps pathologies, and humeral avulsion of the glenohumeral ligament were excluded. Patients were grouped according to direction of instability (anterior, posterior, or combined), and patient characteristics, instability characteristics, suture anchor use, and GBL were compared between the 3 cohorts. In total, 117 patients met the study inclusion criteria. The mean patient age was 29 years, 89.7% were male, the dominant extremity was involved in 63.2%, 65.8% attributed their injuries to a singular traumatic event, and the mean follow-up was 7.9 years. There was no significant difference regarding patient characteristics, injury mechanism, or follow-up time between the 3 cohorts. As compared with the combined-type instability cohort, mean anterior GBL was greater in the anterior instability cohort (8.00% ± 4.40% vs 4.98% ± 5.26% for combined; P = .012), while mean posterior GBL was greater in the posterior instability cohort (7.44% ± 4.54% vs 4.86% ± 5.69% for combined; P = .024). There was no significant difference in mean total GBL between the combined-type (9.84% ± 7.82%) and either of the unidirectional cohorts (anterior: 8.00% ± 4.40% [P = .231]; posterior: 7.44% ± 4.54% [P = .082]). GBL in the direction of instability was found to be significantly greater in the unidirectional versus combined-type instability cohorts.

Background:Glenohumeral instability represents a common cause of shoulder pain anddisability among active-duty members of the military and is associated withthe development of glenoid osteochondral defects.Purpose:To report clinical outcomes and survivorship after combined microfracture ofisolated chondral lesions of the glenoid and labral repair among young,active-duty military patients and to compare outcomes with those of patientswho underwent isolated shoulder stabilization.Study Design:Cohort study; Level of evidence, 3.Methods:Included were 31 active-duty military patients aged <40 years whounderwent simultaneous microfracture of chondral lesions of the glenoid andlabral repair for shoulder instability between January 2011 and January 2017(microfracture group) and 209 patients without chondral defects whounderwent shoulder stabilization during the same time period (instabilitygroup). Preoperative and 5-year postoperative outcomes (range of motion[ROM], visual analog scale [VAS] for pain, Single Assessment NumericEvaluation [SANE] score, American Shoulder and Elbow Surgeons [ASES]shoulder score, and Rowe instability score) were compared within and betweengroups, and separate subgroup analyses were performed to determine whethervariant of instability and dominant-shoulder involvement were associatedwith worse outcomes.Results:The mean follow-up was significantly longer for the microfracture groupversus the instability group (95.58 ± 23.12 vs 83.38 ± 25.93 months;P = .014). Age and sex distributions were similarbetween groups. In both groups, there was significant pre- to postoperativeimprovement on all outcomes scores (P = .0001 for all).When compared with the instability cohort, microfracture patients hadsignificantly worse postoperative VAS pain (2.65 ± 1.78 vs 1.55 ± 1.92;P = .003), SANE (79.13 ± 14.43 vs 91.23 ± 13.20;P < .0001), and ASES (79.90 ± 13.87 vs 89.03 ±14.28; P = .001) scores, as well as decreased ROM inforward flexion (151.29° ± 11.76° vs 155.48° ± 10.3°; P =.039) and external rotation (63.65° ± 8.34° vs 65.17° ± 0.64°;P = .010). At latest follow-up, 58% of microfracturepatients had returned to active-duty military service compared with 93.78%of isolated instability patients (P < .0001).Conclusion:Combined microfracture and arthroscopic labral repair produced modest, albeitstatistically significant, improvements in patient-reported outcome measuresand may be a reasonable treatment option for patients with chondral lesionswho are not candidates for arthroplasty. However, microfracture patients hadsignificantly worse outcomes than patients who underwent stabilizationwithout concomitant chondral defects.

Background: Rotator cuff tears represent a significant cause of shoulder pain and dysfunction in the United States. The development of these injuries is associated with older patient age and higher levels of physical activity; however, data regarding the rate of return to work after arthroscopic rotator cuff repair in patients older than 50 years of age who have physically strenuous jobs is inconclusive. Purpose/Hypothesis: The purpose of this study was to report short term outcomes and return to work rates after arthroscopic rotator cuff repair in a cohort of patients aged 50 to 60 years working in manual labor jobs. It was hypothesized that arthroscopic rotator cuff repair would result in good functional outcomes for these patients and allow for return to work rates in excess of 80%. Study Design: Case series; Level of evidence, 4. Methods: Preoperative and final evaluations including the pain visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score were collected. A total of 73 patients were screened for inclusion. Nineteen patients were outside of the inclusion age range, 2 underwent exclusionary concomitant procedures, and 4 patients were lost to follow up, leaving a total of 48 patients with a mean follow up of 34.02 months (range, 24-67 months) available for analysis. None of the patients were involved in a workers’ compensation claim. Subgroup analysis was performed to determine if arm dominance or tear size affected surgical outcomes or return to work rates. Results: After arthroscopic rotator cuff repair, 43 of 48 patients (89.6%) were able to return to manual labor positions. Tears were classified using the Southern California Orthopaedic Institute Classification at the time of repair as massive (C4) in 9 patients (18.75%), large (C3) in 13 patients (27.08%), medium (C2) in 21 patients (43.75%), and small (C1) in 5 patients (10.42%). At latest follow up, the mean VAS decreased from 8.0 ± 1.81 to 0.46 ± 1.20, the average SANE increased from 47.50 ± 18.59 to 91.88 ± 12.30, and the average ASES score improved from 39.58 ± 10.71 to 93.44 ± 11.97 (P < .0001). Outcomes did not differ between patients who underwent surgery on their dominant shoulder and those who underwent surgery on their nondominant shoulder. The overall postoperative complication rate was 8.33%. Conclusion: Arthroscopic rotator cuff repair portended favorable outcomes and high rates of return to work in this cohort of manual laborers, with 89.6% of patients able to return to work.

LCH is a rare hematopoietic malignancy due to dendritic cell clonal proliferation, which commonly presents as sinusitis. Between 6 and 25% of LCH cases involve the central nervous system (CNS). LCH is rarely associated with other hematologic malignancies, including AML. We describe a 59-year-old patient with LCH of the right frontal sinus metastatic to regional lymph nodes and colon who presented with acute meningoencephalitis and was found to have AML isolated to the CNS. The patient initially presented with antibiotic-refractory recurrent sinusitis and was diagnosed with LCH following sinus biopsy. He was treated with 2 cycles of cytarabine (100 mg/m2 daily x 5 days) but progressed with metastatic disease to lymph nodes and colon (biopsy confirmed). He received 2 cycles of clofarabine with partial response on CT/PET, which was complicated by neutropenia (WBC 0.95, ANC 0.47). He was admitted to the hospital with altered mental status, generalized weakness, and multiple cranial neuropathies. Work up revealed a right frontal dural based mass and cerebrospinal fluid analysis significant for protein >550 mg/dL, glucose <20 mg/dL, and 2105 nucleated cells/mcL. CSF cultures were negative and he did not respond to empiric antibiotics. CSF flow cytometry was consistent with AML, monocytic subtype. Analysis of peripheral blood was notable for pancytopenia without blasts or clonal population of cells. Due to pancytopenia and poor performance status the patient was unable to receive chemotherapy and died on hospice shortly after diagnosis. To the best of our knowledge, this is the only reported case of central nervous systemic AML associated with LCH.

A 43-year-old bodybuilder with a history of anabolic steroid abuse was admitted having been found unresponsive. Examination revealed antecubital fossae contusions but was otherwise unremarkable, as were all initial investigations. Deteriorating Glasgow Coma Score necessitated tracheal intubation. Early attempts at weaning from mechanical ventilation coincided with marked haemodynamic instability and decerebrate posturing to pain with upgoing plantar responses. The patient subsequently became almost completely areflexic, although corneal reflexes were preserved and spontaneous breathing remained. An electroencephalogram showed evidence of a non-specific toxic or metabolic encephalopathy, despite a negative toxicology screen and consistently normal imaging. In the following weeks, a gradual spontaneous improvement occurred. Fourteen weeks after admission, the patient walked out of hospital having made an almost complete recovery. Possible causative factors are discussed, as well as the complications and challenges of managing bodybuilders abusing anabolic agents. These patients require both vigilance and an open mind, as the potential for complications is varied and potentially multi-systemic.

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