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Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World
ABSTRACT
Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.
A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.
There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
Continue to: Reverse total shoulder arthroplasty...
Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.3-5 Al-Hadithy and colleagues6 reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues7 evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.3,8,9
The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.
METHODS
A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.12 A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).13Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine14) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.
A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).15
STATISTICAL ANALYSIS
First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.
Continue to: RESULTS...
RESULTS
There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).
Table 1. Demographic Data by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Number of studies | 52 | 43 | 4 | 4 | 103 | - |
Number of subjects | 6158 | 2609 | 51 | 155 | 8973 | - |
Level of evidence |
|
|
|
|
| 0.693 |
II | 5 (10%) | 3 (7%) | 0 (0%) | 0 (0%) | 8 (8%) |
|
III | 10 (19%) | 4 (9%) | 0 (0%) | 1 (25%) | 15 (15%) |
|
IV | 37 (71%) | 36 (84%) | 4 (100%) | 3 (75%) | 80 (78%) |
|
Mean MCMS | 34.6 ± 8.4 | 40.2 ± 8.0 | 32.5 12.4 | 34.5 ± 6.6 | 36.9 ± 8.7 | 0.010 |
Institutional collaboration |
|
|
|
|
| 1.000 |
Multi-center | 7 (14%) | 6 (14%) | 0 (0%) | 0 (0%) | 13 (13%) |
|
Single-center | 45 (86%) | 37 (86%) | 4 (100%) | 4 (100%) | 90 (87%) |
|
Financial conflict of interest |
|
|
|
|
| 0.005 |
Present | 28 (54%) | 15 (35%) | 0 (0%) | 0 (0%) | 43 (42%) |
|
Not present | 19 (37%) | 16 (37%) | 4 (100%) | 4 (100%) | 43 (42%) |
|
Not reported | 5 (10%) | 12 (28%) | 0 (0%) | 0 (0%) | 17 (17%) |
|
Sex |
|
|
|
|
| N/A |
Male | 2157 (38%) | 1026 (39%) | 13 (25%) | 61 (39%) | 3257 (38%) |
|
Female | 3520 (62%) | 1622 (61%) | 38 (75%) | 94 (61%) | 5274 (62%) |
|
Mean age (years) | 71.3 ± 5.6 | 70.1 ± 7.9 | 68.1 ± 5.3 | 76.9 ± 3.0 | 70.9 ± 6.7 | 0.191 |
Minimum age (mean across studies) | 56.9 ± 12.8 | 52.8 ± 15.7 | 62.8 ± 6.2 | 68.0 ± 12.1 | 55.6 ± 14.3 | 0.160 |
Maximum age (mean across studies) | 82.1 ± 8.6 | 83.0 ± 5.5 | 73.0 ± 9.4 | 85.0 ± 7.9 | 82.2 ± 7.6 | 0.079 |
Mean length of follow-up (months) | 26.5 ± 13.7 | 43.1 ± 21.7 | 29.4 ± 7.9 | 34.2 ± 16.6 | 34.3 ± 19.3 | <0.001 |
Prosthesis type |
|
|
|
|
| N/A |
Cemented | 988 (89%) | 969 (72%) | 0 (0%) | 8 (16%) | 1965 (78%) |
|
Press fit | 120 (11%) | 379 (28%) | 0 (0%) | 41 (84%) | 540 (22%) |
|
Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.
In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).
Continue to: Rotator cuff tear arthropathy...
Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).
Table 2. Number (Percent) of Studies With Each Indication by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Rotator cuff arthropathy | 29 (56%) | 19 (44%) | 3 (75%) | 3 (75%) | 54 (52%) | 0.390 |
Osteoarthritis | 4 (8%) | 10 (23%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.072 |
Rheumatoid arthritis | 9 (17%) | 10 (23%) | 0 (0%) | 2 (50%) | 21 (20%) | 0.278 |
Post-traumatic arthritis | 3 (6%) | 5 (12%) | 0 (0%) | 1 (25%) | 9 (9%) | 0.358 |
Instability | 6 (12%) | 3 (7%) | 0 (0%) | 1 (25%) | 10 (10%) | 0.450 |
Revision of previous RTSA for instability | 5 (10%) | 1 (2%) | 0 (0%) | 1 (25%) | 7 (7%) | 0.192 |
Infection | 4 (8%) | 1 (2%) | 1 (25%) | 0 (0%) | 6 (6%) | 0.207 |
Unclassified acute proximal humerus fracture | 9 (17%) | 5 (12%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.443 |
Acute 2-part proximal humerus fracture | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | N/A |
Acute 3-part proximal humerus fracture | 2 (4%) | 0 (0%) | 0 (0%) | 0 (0%) | 2 (2%) | 0.574 |
Acute 4-part proximal humerus fracture | 5 (10%) | 0 (0%) | 0 (0%) | 0 (0%) | 5 (5%) | 0.183 |
Acute 3- or 4-part proximal humerus fracture | 6 (12%) | 2 (5%) | 0 (0%) | 0 (0%) | 8 (8%) | 0.635 |
Revised from previous nonop proximal humerus fracture | 7 (13%) | 3 (7%) | 0 (0%) | 0 (0%) | 10 (10%) | 0.787 |
Revised from ORIF | 1 (2%) | 1 (2%) | 0 (0%) | 0 (0%) | 2 (2%) | 1.000 |
Revised from CRPP | 0 (0%) | 1 (2%) | 0 (0%) | 0 (0%) | 1 (1%) | 0.495 |
Revised from hemi | 8 (15%) | 4 (9%) | 0 (0%) | 1 (25%) | 13 (13%) | 0.528 |
Revised from TSA | 15 (29%) | 11 (26%) | 0 (0%) | 2 (50%) | 28 (27%) | 0.492 |
Osteonecrosis | 4 (8%) | 2 (5%) | 1 (25%) | 0 (0%) | 7 (7%) | 0.401 |
Pseudoparalysis irreparable tear without arthritis | 20 (38%) | 18 (42%) | 2 (50%) | 1 (25%) | 41 (40%) | 0.919 |
Bone tumors | 0 (0%) | 4 (9.3%) | 0 (0%) | 0 (0%) | 4 (4%) | 0.120 |
Locked shoulder dislocation | 0 (0%) | 0 (0%) | 1 (25%) | 0 (0%) | 1 (1%) | 0.078 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent
| North America | Europe | Asia | Australia | Total |
Rotator cuff arthropathy | 4418 | 895 | 24 | 122 | 5459 |
Osteoarthritis | 90 | 251 | 1 | 14 | 356 |
Rheumatoid arthritis | 59 | 87 | 0 | 2 | 148 |
Post-traumatic arthritis | 62 | 136 | 0 | 1 | 199 |
Instability | 23 | 15 | 0 | 1 | 39 |
Revision of previous RTSA for instability | 29 | 2 | 0 | 1 | 32 |
Infection | 28 | 11 | 2 | 0 | 41 |
Unclassified acute proximal humerus fracture | 42 | 30 | 4 | 8 | 84 |
Acute 3-part proximal humerus fracture | 60 | 0 | 0 | 0 | 6 |
Acute 4-part proximal humerus fracture | 42 | 0 | 0 | 0 | 42 |
Acute 3- or 4-part proximal humerus fracture | 92 | 46 | 0 | 0 | 138 |
Revised from previous nonop proximal humerus fracture | 43 | 53 | 0 | 0 | 96 |
Revised from ORIF | 3 | 9 | 0 | 0 | 12 |
Revised from CRPP | 0 | 3 | 0 | 0 | 3 |
Revised from hemi | 105 | 51 | 0 | 1 | 157 |
Revised from TSA | 192 | 246 | 0 | 5 | 443 |
Osteonecrosis | 9 | 6 | 1 | 0 | 16 |
Pseudoparalysis irreparable tear without arthritis | 535 | 795 | 20 | 2 | 1352 |
Bone tumors | 0 | 38 | 0 | 0 | 38 |
Locked shoulder dislocation | 0 | 0 | 1 | 0 | 1 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).
Table 4. Outcomes by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
DASH | 1 | 2 | 0 | 0 |
|
Preoperative | 54.0 | 62.0 ± 8.5 | - | - | 0.582 |
Postoperative | 24.0 | 32.0 ± 2.8 | - | - | 0.260 |
Change | -30.0 | -30.0 ± 11.3 | - | - | 1.000 |
SPADI | 2 | 0 | 0 | 0 |
|
Preoperative | 80.0 ± 4.2 | - | - | - | N/A |
Postoperative | 34.8 ± 1.1 | - | - | - | N/A |
Change | -45.3 ± 3.2 | - | - | - | N/A |
Absolute constant | 2 | 27 | 0 | 1 |
|
Preopeartive | 33.0 ± 0.0 | 28.2 ± 7.1 | - | 20.0 | 0.329 |
Postoperative | 54.5 ± 7.8 | 62.9 ± 9.0 | - | 65.0 | 0.432 |
Change | +21.5 ± 7.8 | +34.7 ± 8.0 | - | +45.0 | 0.044 |
ASES | 13 | 0 | 2 | 0 |
|
Preoperative | 33.2 ± 5.4 | - | 32.5 ± 3.5 | - | 0.867 |
Postoperative | 73.9 ± 6.8 | - | 75.7 ± 10.8 | - | 0.752 |
Change | +40.7 ± 6.5 | - | +43.2 ± 14.4 | - | 0.670 |
UCLA | 3 | 2 | 1 | 0 |
|
Preoperative | 10.1 ± 3.4 | 11.2 ± 5.7 | 12.0 | - | 0.925 |
Postoperative | 24.5 ± 3.1 | 24.3 ± 3.7 | 24.0 | - | 0.991 |
Change | +14.4 ± 1.6 | +13.1 ± 2.0 | +12.0 | - | 0.524 |
KSS | 0 | 0 | 2 | 0 |
|
Preopeartive | - | - | 38.2 ± 1.1 | - | N/A |
Postoperative | - | - | 72.3 ± 6.0 | - | N/A |
Change | - | - | +34.1 ± 7.1 | - | N/A |
SST-12 | 12 | 1 | 0 | 0 |
|
Preoperative | 1.9 ± 0.8 | 1.2 | - | - | N/A |
Postoperative | 7.1 ± 1.5 | 5.6 | - | - | N/A |
Change | +5.3 ± 1.2 | +4.4 | - | - | N/A |
SF-12 | 1 | 0 | 0 | 0 |
|
Preoperative | 34.5 | - | - | - | N/A |
Postoperative | 38.5 | - | - | - | N/A |
Change | +4.0 | - | - | - | N/A |
SSV | 0 | 5 | 0 | 0 |
|
Preopeartive | - | 22.0 ± 7.4 | - | - | N/A |
Postoperative | - | 63.4 ± 7.9 | - | - | N/A |
Change | - | +41.4 ± 2.1 | - | - | N/A |
EQ-5D | 0 | 2 | 0 | 0 |
|
Preoperative | - | 0.5 ± 0.2 | - | - | N/A |
Postoperative | - | 0.8 ± 0.1 | - | - | N/A |
Change | - | +0.3 ± 0.1 | - | - | N/A |
OOS | 1 | 0 | 0 | 0 |
|
Preoperative | 24.7 | - | - | - | N/A |
Postoperative | 14.9 | - | - | - | N/A |
Change | -9.9 | - | - | - | N/A |
Rowe | 0 | 1 | 0 | 0 |
|
Preoperative | - | 50.2 | - | - | N/A |
Postoperative | - | 82.1 | - | - | N/A |
Change | - | 31.9 | - | - | N/A |
Oxford | 0 | 2 | 0 | 0 |
|
Preoperative | - | 119.9 ± 138.8 | - | - | N/A |
Postoperative | - | 39.9 ± 3.3 | - | - | N/A |
Change | - | -80.6 ± 142.2 | - | - | N/A |
Penn | 1 | 0 | 0 | 0 |
|
Preoperative | 24.9 | - | - | - | N/A |
Postoperative | 66.4 | - | - | - | N/A |
Change | +41.5 | - | - | - | N/A |
VAS | 10 | 1 | 1 | 1 |
|
Preoperative | 6.6 ± 0.8 | 7.0 | 8.4 | 7.0 | N/A |
Postoperative | 2.0 ± 0.7 | 1.0 | 0.8 | 0.8 | N/A |
Change | -4.6 ± 0.8 | -6.0 | -7.6 | -6.2 | N/A |
SF-36 physical | 2 | 0 | 0 | 0 |
|
Preoperative | 32.7 ± 1.2 | - | - | - | N/A |
Postoperative | 39.6 ± 4.0 | - | - | - | N/A |
Change | +7.0 ± 2.8 | - | - | - | N/A |
SF-36 mental | 2 | 0 | 0 | 0 |
|
Preoperative | 43.6 ± 2.8 | - | - | - | N/A |
Postoperative | 48.1 ± 1.0 | - | - | - | N/A |
Change | +4.5 ± 1.8 | - | - | - | N/A |
Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.
Table 5. Shoulder Range of Motion, by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
Flexion | 18 | 22 | 1 | 1 |
|
Preoperative | 57.6 ± 17.9 | 65.5 ± 17.2 | 91.0 | 30.0 | 0.060 |
Postoperative | 126.6 ± 14.4 | 121.8 ± 19.0 | 133.0 | 150.0 | 0.360 |
Change | +69.0 ± 24.5 | +56.3 ± 11.3 | +42.0 | 120.0 | 0.004 |
Abduction | 11 | 12 | 1 | 0 |
|
Preoperative | 53.7 ± 25.0 | 52.0 ± 19.0 | 88.0 | - | 0.311 |
Postoperative | 109.3 ± 15.1 | 105.4 ± 19.8 | 131.0 | - | 0.386 |
Change | 55.5 ± 25.5 | 53.3 ± 8.3 | 43.0 | - | 0.804 |
External rotation | 17 | 19 | 0 | 0 |
|
Preoperative | 19.4 ± 9.9 | 11.2 ± 6.1 | - | - | 0.005 |
Postoperative | 34.1 ± 13.3 | 19.3 ± 8.9 | - | - | <0.001 |
Change | +14.7 ± 13.2 | +8.1 ± 8.5 | - | - | 0.079 |
Continue to: DISCUSSION...
DISCUSSION
RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.
RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.10 This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.11 Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.16,17 Frankle and colleagues16 evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues17 evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).
It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.18 Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.19 However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.20
Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.6,21,22
One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.23 This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.26 However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.27 With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.
LIMITATIONS
Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.
CONCLUSION
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
This paper will be judged for the Resident Writer’s Award.
1. Boileau P, Moineau G, Roussanne Y, O'Shea K. Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469(9):2558-2567. doi:10.1007/s11999-011-1775-4.
2. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4,500 patients. J Orthop Trauma. 2014;29(1):54-59.
3. Cazeneuve JF, Cristofari DJ. Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up. Orthop Traumatol Surg Res. 2014;100(1):93-97. doi:10.1016/j.otsr.2013.12.005.
4. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41. doi:10.1016/j.jse.2011.04.009.
5. De Biase CF, Delcogliano M, Borroni M, Castagna A. Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere. Musculoskelet Surg. 2012;96(suppl 1):S27-SS34. doi:10.1007/s12306-012-0193-4.
6. Al-Hadithy N, Domos P, Sewell MD, Pandit R. Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years. J Shoulder Elbow Surg. 2014;23(11):1662-1668. doi:10.1016/j.jse.2014.03.001.
7. Ross M, Hope B, Stokes A, Peters SE, McLeod I, Duke PF. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015;24(2):215-222. doi:10.1016/j.jse.2014.05.022.
8. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544-2556. doi:10.2106/JBJS.I.00912.
9. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2015;24(6):988-993. doi:10.1016/j.jse.2015.01.001.
10. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(1):91-97. doi:10.1016/j.jse.2014.08.026.
11. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.
12. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. doi:10.1016/j.jclinepi.2009.06.006.
13. University of York Centre for Reviews and Dissemination, National Institute for Health Research. PROSPERO International prospective register of systematic reviews. University of York Web site. http://www.crd.york.ac.uk/PROSPERO/. Accessed November 1, 2016.
14. Oxford Centre for Evidence-based Medicine – Levels of evidence (March 2009). University of Oxford Web site: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed November 1, 2016.
15. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699. doi:10.2106/JBJS.F.00858.
16. Frankle M, Levy JC, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 2):178-190. doi:10.2106/JBJS.F.00123.
17. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486. doi:10.2106/JBJS.D.02342.
18. Peppers TA, Jobe CM, Dai QG, Williams PA, Libanati C. Fixation of humeral prostheses and axial micromotion. J Shoulder Elbow Surg. 1998;7(4):414-418. doi:10.1016/S1058-2746(98)90034-9.
19. Wiater JM, Moravek JE Jr, Budge MD, Koueiter DM, Marcantonio D, Wiater BP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214. doi:10.1016/j.jse.2013.11.032.
20. Nowinski RJ, Gillespie RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. J Shoulder Elbow Surg. 2012;21(3):324-328. doi:10.1016/j.jse.2011.08.072.
21. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y.
22. Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57-61. doi:10.1302/0301-620X.93B1.24218.
23. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467. doi:10.1016/j.jse.2014.08.016.
24. Coe MP, Greiwe RM, Joshi R, et al. The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012;21(10):1278-1288. doi:10.1016/j.jse.2011.10.010.
25. Renfree KJ, Hattrup SJ, Chang YH. Cost utility analysis of reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(12):1656-1661. doi:10.1016/j.jse.2013.08.002.
26. Chalmers PN, Slikker W, 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204. doi:10.1016/j.jse.2013.07.044.
27. Steen BM, Cabezas AF, Santoni BG, et al. Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg. 2015;24(9):1433-1441. doi:10.1016/j.jse.2015.01.005.
ABSTRACT
Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.
A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.
There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
Continue to: Reverse total shoulder arthroplasty...
Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.3-5 Al-Hadithy and colleagues6 reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues7 evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.3,8,9
The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.
METHODS
A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.12 A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).13Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine14) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.
A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).15
STATISTICAL ANALYSIS
First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.
Continue to: RESULTS...
RESULTS
There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).
Table 1. Demographic Data by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Number of studies | 52 | 43 | 4 | 4 | 103 | - |
Number of subjects | 6158 | 2609 | 51 | 155 | 8973 | - |
Level of evidence |
|
|
|
|
| 0.693 |
II | 5 (10%) | 3 (7%) | 0 (0%) | 0 (0%) | 8 (8%) |
|
III | 10 (19%) | 4 (9%) | 0 (0%) | 1 (25%) | 15 (15%) |
|
IV | 37 (71%) | 36 (84%) | 4 (100%) | 3 (75%) | 80 (78%) |
|
Mean MCMS | 34.6 ± 8.4 | 40.2 ± 8.0 | 32.5 12.4 | 34.5 ± 6.6 | 36.9 ± 8.7 | 0.010 |
Institutional collaboration |
|
|
|
|
| 1.000 |
Multi-center | 7 (14%) | 6 (14%) | 0 (0%) | 0 (0%) | 13 (13%) |
|
Single-center | 45 (86%) | 37 (86%) | 4 (100%) | 4 (100%) | 90 (87%) |
|
Financial conflict of interest |
|
|
|
|
| 0.005 |
Present | 28 (54%) | 15 (35%) | 0 (0%) | 0 (0%) | 43 (42%) |
|
Not present | 19 (37%) | 16 (37%) | 4 (100%) | 4 (100%) | 43 (42%) |
|
Not reported | 5 (10%) | 12 (28%) | 0 (0%) | 0 (0%) | 17 (17%) |
|
Sex |
|
|
|
|
| N/A |
Male | 2157 (38%) | 1026 (39%) | 13 (25%) | 61 (39%) | 3257 (38%) |
|
Female | 3520 (62%) | 1622 (61%) | 38 (75%) | 94 (61%) | 5274 (62%) |
|
Mean age (years) | 71.3 ± 5.6 | 70.1 ± 7.9 | 68.1 ± 5.3 | 76.9 ± 3.0 | 70.9 ± 6.7 | 0.191 |
Minimum age (mean across studies) | 56.9 ± 12.8 | 52.8 ± 15.7 | 62.8 ± 6.2 | 68.0 ± 12.1 | 55.6 ± 14.3 | 0.160 |
Maximum age (mean across studies) | 82.1 ± 8.6 | 83.0 ± 5.5 | 73.0 ± 9.4 | 85.0 ± 7.9 | 82.2 ± 7.6 | 0.079 |
Mean length of follow-up (months) | 26.5 ± 13.7 | 43.1 ± 21.7 | 29.4 ± 7.9 | 34.2 ± 16.6 | 34.3 ± 19.3 | <0.001 |
Prosthesis type |
|
|
|
|
| N/A |
Cemented | 988 (89%) | 969 (72%) | 0 (0%) | 8 (16%) | 1965 (78%) |
|
Press fit | 120 (11%) | 379 (28%) | 0 (0%) | 41 (84%) | 540 (22%) |
|
Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.
In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).
Continue to: Rotator cuff tear arthropathy...
Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).
Table 2. Number (Percent) of Studies With Each Indication by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Rotator cuff arthropathy | 29 (56%) | 19 (44%) | 3 (75%) | 3 (75%) | 54 (52%) | 0.390 |
Osteoarthritis | 4 (8%) | 10 (23%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.072 |
Rheumatoid arthritis | 9 (17%) | 10 (23%) | 0 (0%) | 2 (50%) | 21 (20%) | 0.278 |
Post-traumatic arthritis | 3 (6%) | 5 (12%) | 0 (0%) | 1 (25%) | 9 (9%) | 0.358 |
Instability | 6 (12%) | 3 (7%) | 0 (0%) | 1 (25%) | 10 (10%) | 0.450 |
Revision of previous RTSA for instability | 5 (10%) | 1 (2%) | 0 (0%) | 1 (25%) | 7 (7%) | 0.192 |
Infection | 4 (8%) | 1 (2%) | 1 (25%) | 0 (0%) | 6 (6%) | 0.207 |
Unclassified acute proximal humerus fracture | 9 (17%) | 5 (12%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.443 |
Acute 2-part proximal humerus fracture | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | N/A |
Acute 3-part proximal humerus fracture | 2 (4%) | 0 (0%) | 0 (0%) | 0 (0%) | 2 (2%) | 0.574 |
Acute 4-part proximal humerus fracture | 5 (10%) | 0 (0%) | 0 (0%) | 0 (0%) | 5 (5%) | 0.183 |
Acute 3- or 4-part proximal humerus fracture | 6 (12%) | 2 (5%) | 0 (0%) | 0 (0%) | 8 (8%) | 0.635 |
Revised from previous nonop proximal humerus fracture | 7 (13%) | 3 (7%) | 0 (0%) | 0 (0%) | 10 (10%) | 0.787 |
Revised from ORIF | 1 (2%) | 1 (2%) | 0 (0%) | 0 (0%) | 2 (2%) | 1.000 |
Revised from CRPP | 0 (0%) | 1 (2%) | 0 (0%) | 0 (0%) | 1 (1%) | 0.495 |
Revised from hemi | 8 (15%) | 4 (9%) | 0 (0%) | 1 (25%) | 13 (13%) | 0.528 |
Revised from TSA | 15 (29%) | 11 (26%) | 0 (0%) | 2 (50%) | 28 (27%) | 0.492 |
Osteonecrosis | 4 (8%) | 2 (5%) | 1 (25%) | 0 (0%) | 7 (7%) | 0.401 |
Pseudoparalysis irreparable tear without arthritis | 20 (38%) | 18 (42%) | 2 (50%) | 1 (25%) | 41 (40%) | 0.919 |
Bone tumors | 0 (0%) | 4 (9.3%) | 0 (0%) | 0 (0%) | 4 (4%) | 0.120 |
Locked shoulder dislocation | 0 (0%) | 0 (0%) | 1 (25%) | 0 (0%) | 1 (1%) | 0.078 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent
| North America | Europe | Asia | Australia | Total |
Rotator cuff arthropathy | 4418 | 895 | 24 | 122 | 5459 |
Osteoarthritis | 90 | 251 | 1 | 14 | 356 |
Rheumatoid arthritis | 59 | 87 | 0 | 2 | 148 |
Post-traumatic arthritis | 62 | 136 | 0 | 1 | 199 |
Instability | 23 | 15 | 0 | 1 | 39 |
Revision of previous RTSA for instability | 29 | 2 | 0 | 1 | 32 |
Infection | 28 | 11 | 2 | 0 | 41 |
Unclassified acute proximal humerus fracture | 42 | 30 | 4 | 8 | 84 |
Acute 3-part proximal humerus fracture | 60 | 0 | 0 | 0 | 6 |
Acute 4-part proximal humerus fracture | 42 | 0 | 0 | 0 | 42 |
Acute 3- or 4-part proximal humerus fracture | 92 | 46 | 0 | 0 | 138 |
Revised from previous nonop proximal humerus fracture | 43 | 53 | 0 | 0 | 96 |
Revised from ORIF | 3 | 9 | 0 | 0 | 12 |
Revised from CRPP | 0 | 3 | 0 | 0 | 3 |
Revised from hemi | 105 | 51 | 0 | 1 | 157 |
Revised from TSA | 192 | 246 | 0 | 5 | 443 |
Osteonecrosis | 9 | 6 | 1 | 0 | 16 |
Pseudoparalysis irreparable tear without arthritis | 535 | 795 | 20 | 2 | 1352 |
Bone tumors | 0 | 38 | 0 | 0 | 38 |
Locked shoulder dislocation | 0 | 0 | 1 | 0 | 1 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).
Table 4. Outcomes by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
DASH | 1 | 2 | 0 | 0 |
|
Preoperative | 54.0 | 62.0 ± 8.5 | - | - | 0.582 |
Postoperative | 24.0 | 32.0 ± 2.8 | - | - | 0.260 |
Change | -30.0 | -30.0 ± 11.3 | - | - | 1.000 |
SPADI | 2 | 0 | 0 | 0 |
|
Preoperative | 80.0 ± 4.2 | - | - | - | N/A |
Postoperative | 34.8 ± 1.1 | - | - | - | N/A |
Change | -45.3 ± 3.2 | - | - | - | N/A |
Absolute constant | 2 | 27 | 0 | 1 |
|
Preopeartive | 33.0 ± 0.0 | 28.2 ± 7.1 | - | 20.0 | 0.329 |
Postoperative | 54.5 ± 7.8 | 62.9 ± 9.0 | - | 65.0 | 0.432 |
Change | +21.5 ± 7.8 | +34.7 ± 8.0 | - | +45.0 | 0.044 |
ASES | 13 | 0 | 2 | 0 |
|
Preoperative | 33.2 ± 5.4 | - | 32.5 ± 3.5 | - | 0.867 |
Postoperative | 73.9 ± 6.8 | - | 75.7 ± 10.8 | - | 0.752 |
Change | +40.7 ± 6.5 | - | +43.2 ± 14.4 | - | 0.670 |
UCLA | 3 | 2 | 1 | 0 |
|
Preoperative | 10.1 ± 3.4 | 11.2 ± 5.7 | 12.0 | - | 0.925 |
Postoperative | 24.5 ± 3.1 | 24.3 ± 3.7 | 24.0 | - | 0.991 |
Change | +14.4 ± 1.6 | +13.1 ± 2.0 | +12.0 | - | 0.524 |
KSS | 0 | 0 | 2 | 0 |
|
Preopeartive | - | - | 38.2 ± 1.1 | - | N/A |
Postoperative | - | - | 72.3 ± 6.0 | - | N/A |
Change | - | - | +34.1 ± 7.1 | - | N/A |
SST-12 | 12 | 1 | 0 | 0 |
|
Preoperative | 1.9 ± 0.8 | 1.2 | - | - | N/A |
Postoperative | 7.1 ± 1.5 | 5.6 | - | - | N/A |
Change | +5.3 ± 1.2 | +4.4 | - | - | N/A |
SF-12 | 1 | 0 | 0 | 0 |
|
Preoperative | 34.5 | - | - | - | N/A |
Postoperative | 38.5 | - | - | - | N/A |
Change | +4.0 | - | - | - | N/A |
SSV | 0 | 5 | 0 | 0 |
|
Preopeartive | - | 22.0 ± 7.4 | - | - | N/A |
Postoperative | - | 63.4 ± 7.9 | - | - | N/A |
Change | - | +41.4 ± 2.1 | - | - | N/A |
EQ-5D | 0 | 2 | 0 | 0 |
|
Preoperative | - | 0.5 ± 0.2 | - | - | N/A |
Postoperative | - | 0.8 ± 0.1 | - | - | N/A |
Change | - | +0.3 ± 0.1 | - | - | N/A |
OOS | 1 | 0 | 0 | 0 |
|
Preoperative | 24.7 | - | - | - | N/A |
Postoperative | 14.9 | - | - | - | N/A |
Change | -9.9 | - | - | - | N/A |
Rowe | 0 | 1 | 0 | 0 |
|
Preoperative | - | 50.2 | - | - | N/A |
Postoperative | - | 82.1 | - | - | N/A |
Change | - | 31.9 | - | - | N/A |
Oxford | 0 | 2 | 0 | 0 |
|
Preoperative | - | 119.9 ± 138.8 | - | - | N/A |
Postoperative | - | 39.9 ± 3.3 | - | - | N/A |
Change | - | -80.6 ± 142.2 | - | - | N/A |
Penn | 1 | 0 | 0 | 0 |
|
Preoperative | 24.9 | - | - | - | N/A |
Postoperative | 66.4 | - | - | - | N/A |
Change | +41.5 | - | - | - | N/A |
VAS | 10 | 1 | 1 | 1 |
|
Preoperative | 6.6 ± 0.8 | 7.0 | 8.4 | 7.0 | N/A |
Postoperative | 2.0 ± 0.7 | 1.0 | 0.8 | 0.8 | N/A |
Change | -4.6 ± 0.8 | -6.0 | -7.6 | -6.2 | N/A |
SF-36 physical | 2 | 0 | 0 | 0 |
|
Preoperative | 32.7 ± 1.2 | - | - | - | N/A |
Postoperative | 39.6 ± 4.0 | - | - | - | N/A |
Change | +7.0 ± 2.8 | - | - | - | N/A |
SF-36 mental | 2 | 0 | 0 | 0 |
|
Preoperative | 43.6 ± 2.8 | - | - | - | N/A |
Postoperative | 48.1 ± 1.0 | - | - | - | N/A |
Change | +4.5 ± 1.8 | - | - | - | N/A |
Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.
Table 5. Shoulder Range of Motion, by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
Flexion | 18 | 22 | 1 | 1 |
|
Preoperative | 57.6 ± 17.9 | 65.5 ± 17.2 | 91.0 | 30.0 | 0.060 |
Postoperative | 126.6 ± 14.4 | 121.8 ± 19.0 | 133.0 | 150.0 | 0.360 |
Change | +69.0 ± 24.5 | +56.3 ± 11.3 | +42.0 | 120.0 | 0.004 |
Abduction | 11 | 12 | 1 | 0 |
|
Preoperative | 53.7 ± 25.0 | 52.0 ± 19.0 | 88.0 | - | 0.311 |
Postoperative | 109.3 ± 15.1 | 105.4 ± 19.8 | 131.0 | - | 0.386 |
Change | 55.5 ± 25.5 | 53.3 ± 8.3 | 43.0 | - | 0.804 |
External rotation | 17 | 19 | 0 | 0 |
|
Preoperative | 19.4 ± 9.9 | 11.2 ± 6.1 | - | - | 0.005 |
Postoperative | 34.1 ± 13.3 | 19.3 ± 8.9 | - | - | <0.001 |
Change | +14.7 ± 13.2 | +8.1 ± 8.5 | - | - | 0.079 |
Continue to: DISCUSSION...
DISCUSSION
RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.
RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.10 This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.11 Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.16,17 Frankle and colleagues16 evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues17 evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).
It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.18 Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.19 However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.20
Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.6,21,22
One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.23 This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.26 However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.27 With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.
LIMITATIONS
Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.
CONCLUSION
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.
A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.
There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
Continue to: Reverse total shoulder arthroplasty...
Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.3-5 Al-Hadithy and colleagues6 reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues7 evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.3,8,9
The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.
METHODS
A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.12 A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).13Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine14) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.
A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).15
STATISTICAL ANALYSIS
First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.
Continue to: RESULTS...
RESULTS
There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).
Table 1. Demographic Data by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Number of studies | 52 | 43 | 4 | 4 | 103 | - |
Number of subjects | 6158 | 2609 | 51 | 155 | 8973 | - |
Level of evidence |
|
|
|
|
| 0.693 |
II | 5 (10%) | 3 (7%) | 0 (0%) | 0 (0%) | 8 (8%) |
|
III | 10 (19%) | 4 (9%) | 0 (0%) | 1 (25%) | 15 (15%) |
|
IV | 37 (71%) | 36 (84%) | 4 (100%) | 3 (75%) | 80 (78%) |
|
Mean MCMS | 34.6 ± 8.4 | 40.2 ± 8.0 | 32.5 12.4 | 34.5 ± 6.6 | 36.9 ± 8.7 | 0.010 |
Institutional collaboration |
|
|
|
|
| 1.000 |
Multi-center | 7 (14%) | 6 (14%) | 0 (0%) | 0 (0%) | 13 (13%) |
|
Single-center | 45 (86%) | 37 (86%) | 4 (100%) | 4 (100%) | 90 (87%) |
|
Financial conflict of interest |
|
|
|
|
| 0.005 |
Present | 28 (54%) | 15 (35%) | 0 (0%) | 0 (0%) | 43 (42%) |
|
Not present | 19 (37%) | 16 (37%) | 4 (100%) | 4 (100%) | 43 (42%) |
|
Not reported | 5 (10%) | 12 (28%) | 0 (0%) | 0 (0%) | 17 (17%) |
|
Sex |
|
|
|
|
| N/A |
Male | 2157 (38%) | 1026 (39%) | 13 (25%) | 61 (39%) | 3257 (38%) |
|
Female | 3520 (62%) | 1622 (61%) | 38 (75%) | 94 (61%) | 5274 (62%) |
|
Mean age (years) | 71.3 ± 5.6 | 70.1 ± 7.9 | 68.1 ± 5.3 | 76.9 ± 3.0 | 70.9 ± 6.7 | 0.191 |
Minimum age (mean across studies) | 56.9 ± 12.8 | 52.8 ± 15.7 | 62.8 ± 6.2 | 68.0 ± 12.1 | 55.6 ± 14.3 | 0.160 |
Maximum age (mean across studies) | 82.1 ± 8.6 | 83.0 ± 5.5 | 73.0 ± 9.4 | 85.0 ± 7.9 | 82.2 ± 7.6 | 0.079 |
Mean length of follow-up (months) | 26.5 ± 13.7 | 43.1 ± 21.7 | 29.4 ± 7.9 | 34.2 ± 16.6 | 34.3 ± 19.3 | <0.001 |
Prosthesis type |
|
|
|
|
| N/A |
Cemented | 988 (89%) | 969 (72%) | 0 (0%) | 8 (16%) | 1965 (78%) |
|
Press fit | 120 (11%) | 379 (28%) | 0 (0%) | 41 (84%) | 540 (22%) |
|
Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.
In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).
Continue to: Rotator cuff tear arthropathy...
Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).
Table 2. Number (Percent) of Studies With Each Indication by Continent
| North America | Europe | Asia | Australia | Total | P-value |
Rotator cuff arthropathy | 29 (56%) | 19 (44%) | 3 (75%) | 3 (75%) | 54 (52%) | 0.390 |
Osteoarthritis | 4 (8%) | 10 (23%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.072 |
Rheumatoid arthritis | 9 (17%) | 10 (23%) | 0 (0%) | 2 (50%) | 21 (20%) | 0.278 |
Post-traumatic arthritis | 3 (6%) | 5 (12%) | 0 (0%) | 1 (25%) | 9 (9%) | 0.358 |
Instability | 6 (12%) | 3 (7%) | 0 (0%) | 1 (25%) | 10 (10%) | 0.450 |
Revision of previous RTSA for instability | 5 (10%) | 1 (2%) | 0 (0%) | 1 (25%) | 7 (7%) | 0.192 |
Infection | 4 (8%) | 1 (2%) | 1 (25%) | 0 (0%) | 6 (6%) | 0.207 |
Unclassified acute proximal humerus fracture | 9 (17%) | 5 (12%) | 1 (25%) | 1 (25%) | 16 (16%) | 0.443 |
Acute 2-part proximal humerus fracture | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | N/A |
Acute 3-part proximal humerus fracture | 2 (4%) | 0 (0%) | 0 (0%) | 0 (0%) | 2 (2%) | 0.574 |
Acute 4-part proximal humerus fracture | 5 (10%) | 0 (0%) | 0 (0%) | 0 (0%) | 5 (5%) | 0.183 |
Acute 3- or 4-part proximal humerus fracture | 6 (12%) | 2 (5%) | 0 (0%) | 0 (0%) | 8 (8%) | 0.635 |
Revised from previous nonop proximal humerus fracture | 7 (13%) | 3 (7%) | 0 (0%) | 0 (0%) | 10 (10%) | 0.787 |
Revised from ORIF | 1 (2%) | 1 (2%) | 0 (0%) | 0 (0%) | 2 (2%) | 1.000 |
Revised from CRPP | 0 (0%) | 1 (2%) | 0 (0%) | 0 (0%) | 1 (1%) | 0.495 |
Revised from hemi | 8 (15%) | 4 (9%) | 0 (0%) | 1 (25%) | 13 (13%) | 0.528 |
Revised from TSA | 15 (29%) | 11 (26%) | 0 (0%) | 2 (50%) | 28 (27%) | 0.492 |
Osteonecrosis | 4 (8%) | 2 (5%) | 1 (25%) | 0 (0%) | 7 (7%) | 0.401 |
Pseudoparalysis irreparable tear without arthritis | 20 (38%) | 18 (42%) | 2 (50%) | 1 (25%) | 41 (40%) | 0.919 |
Bone tumors | 0 (0%) | 4 (9.3%) | 0 (0%) | 0 (0%) | 4 (4%) | 0.120 |
Locked shoulder dislocation | 0 (0%) | 0 (0%) | 1 (25%) | 0 (0%) | 1 (1%) | 0.078 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent
| North America | Europe | Asia | Australia | Total |
Rotator cuff arthropathy | 4418 | 895 | 24 | 122 | 5459 |
Osteoarthritis | 90 | 251 | 1 | 14 | 356 |
Rheumatoid arthritis | 59 | 87 | 0 | 2 | 148 |
Post-traumatic arthritis | 62 | 136 | 0 | 1 | 199 |
Instability | 23 | 15 | 0 | 1 | 39 |
Revision of previous RTSA for instability | 29 | 2 | 0 | 1 | 32 |
Infection | 28 | 11 | 2 | 0 | 41 |
Unclassified acute proximal humerus fracture | 42 | 30 | 4 | 8 | 84 |
Acute 3-part proximal humerus fracture | 60 | 0 | 0 | 0 | 6 |
Acute 4-part proximal humerus fracture | 42 | 0 | 0 | 0 | 42 |
Acute 3- or 4-part proximal humerus fracture | 92 | 46 | 0 | 0 | 138 |
Revised from previous nonop proximal humerus fracture | 43 | 53 | 0 | 0 | 96 |
Revised from ORIF | 3 | 9 | 0 | 0 | 12 |
Revised from CRPP | 0 | 3 | 0 | 0 | 3 |
Revised from hemi | 105 | 51 | 0 | 1 | 157 |
Revised from TSA | 192 | 246 | 0 | 5 | 443 |
Osteonecrosis | 9 | 6 | 1 | 0 | 16 |
Pseudoparalysis irreparable tear without arthritis | 535 | 795 | 20 | 2 | 1352 |
Bone tumors | 0 | 38 | 0 | 0 | 38 |
Locked shoulder dislocation | 0 | 0 | 1 | 0 | 1 |
Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.
The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).
Table 4. Outcomes by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
DASH | 1 | 2 | 0 | 0 |
|
Preoperative | 54.0 | 62.0 ± 8.5 | - | - | 0.582 |
Postoperative | 24.0 | 32.0 ± 2.8 | - | - | 0.260 |
Change | -30.0 | -30.0 ± 11.3 | - | - | 1.000 |
SPADI | 2 | 0 | 0 | 0 |
|
Preoperative | 80.0 ± 4.2 | - | - | - | N/A |
Postoperative | 34.8 ± 1.1 | - | - | - | N/A |
Change | -45.3 ± 3.2 | - | - | - | N/A |
Absolute constant | 2 | 27 | 0 | 1 |
|
Preopeartive | 33.0 ± 0.0 | 28.2 ± 7.1 | - | 20.0 | 0.329 |
Postoperative | 54.5 ± 7.8 | 62.9 ± 9.0 | - | 65.0 | 0.432 |
Change | +21.5 ± 7.8 | +34.7 ± 8.0 | - | +45.0 | 0.044 |
ASES | 13 | 0 | 2 | 0 |
|
Preoperative | 33.2 ± 5.4 | - | 32.5 ± 3.5 | - | 0.867 |
Postoperative | 73.9 ± 6.8 | - | 75.7 ± 10.8 | - | 0.752 |
Change | +40.7 ± 6.5 | - | +43.2 ± 14.4 | - | 0.670 |
UCLA | 3 | 2 | 1 | 0 |
|
Preoperative | 10.1 ± 3.4 | 11.2 ± 5.7 | 12.0 | - | 0.925 |
Postoperative | 24.5 ± 3.1 | 24.3 ± 3.7 | 24.0 | - | 0.991 |
Change | +14.4 ± 1.6 | +13.1 ± 2.0 | +12.0 | - | 0.524 |
KSS | 0 | 0 | 2 | 0 |
|
Preopeartive | - | - | 38.2 ± 1.1 | - | N/A |
Postoperative | - | - | 72.3 ± 6.0 | - | N/A |
Change | - | - | +34.1 ± 7.1 | - | N/A |
SST-12 | 12 | 1 | 0 | 0 |
|
Preoperative | 1.9 ± 0.8 | 1.2 | - | - | N/A |
Postoperative | 7.1 ± 1.5 | 5.6 | - | - | N/A |
Change | +5.3 ± 1.2 | +4.4 | - | - | N/A |
SF-12 | 1 | 0 | 0 | 0 |
|
Preoperative | 34.5 | - | - | - | N/A |
Postoperative | 38.5 | - | - | - | N/A |
Change | +4.0 | - | - | - | N/A |
SSV | 0 | 5 | 0 | 0 |
|
Preopeartive | - | 22.0 ± 7.4 | - | - | N/A |
Postoperative | - | 63.4 ± 7.9 | - | - | N/A |
Change | - | +41.4 ± 2.1 | - | - | N/A |
EQ-5D | 0 | 2 | 0 | 0 |
|
Preoperative | - | 0.5 ± 0.2 | - | - | N/A |
Postoperative | - | 0.8 ± 0.1 | - | - | N/A |
Change | - | +0.3 ± 0.1 | - | - | N/A |
OOS | 1 | 0 | 0 | 0 |
|
Preoperative | 24.7 | - | - | - | N/A |
Postoperative | 14.9 | - | - | - | N/A |
Change | -9.9 | - | - | - | N/A |
Rowe | 0 | 1 | 0 | 0 |
|
Preoperative | - | 50.2 | - | - | N/A |
Postoperative | - | 82.1 | - | - | N/A |
Change | - | 31.9 | - | - | N/A |
Oxford | 0 | 2 | 0 | 0 |
|
Preoperative | - | 119.9 ± 138.8 | - | - | N/A |
Postoperative | - | 39.9 ± 3.3 | - | - | N/A |
Change | - | -80.6 ± 142.2 | - | - | N/A |
Penn | 1 | 0 | 0 | 0 |
|
Preoperative | 24.9 | - | - | - | N/A |
Postoperative | 66.4 | - | - | - | N/A |
Change | +41.5 | - | - | - | N/A |
VAS | 10 | 1 | 1 | 1 |
|
Preoperative | 6.6 ± 0.8 | 7.0 | 8.4 | 7.0 | N/A |
Postoperative | 2.0 ± 0.7 | 1.0 | 0.8 | 0.8 | N/A |
Change | -4.6 ± 0.8 | -6.0 | -7.6 | -6.2 | N/A |
SF-36 physical | 2 | 0 | 0 | 0 |
|
Preoperative | 32.7 ± 1.2 | - | - | - | N/A |
Postoperative | 39.6 ± 4.0 | - | - | - | N/A |
Change | +7.0 ± 2.8 | - | - | - | N/A |
SF-36 mental | 2 | 0 | 0 | 0 |
|
Preoperative | 43.6 ± 2.8 | - | - | - | N/A |
Postoperative | 48.1 ± 1.0 | - | - | - | N/A |
Change | +4.5 ± 1.8 | - | - | - | N/A |
Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.
Table 5. Shoulder Range of Motion, by Continent
Metric (number of studies) | North America | Europe | Asia | Australia | P-value |
Flexion | 18 | 22 | 1 | 1 |
|
Preoperative | 57.6 ± 17.9 | 65.5 ± 17.2 | 91.0 | 30.0 | 0.060 |
Postoperative | 126.6 ± 14.4 | 121.8 ± 19.0 | 133.0 | 150.0 | 0.360 |
Change | +69.0 ± 24.5 | +56.3 ± 11.3 | +42.0 | 120.0 | 0.004 |
Abduction | 11 | 12 | 1 | 0 |
|
Preoperative | 53.7 ± 25.0 | 52.0 ± 19.0 | 88.0 | - | 0.311 |
Postoperative | 109.3 ± 15.1 | 105.4 ± 19.8 | 131.0 | - | 0.386 |
Change | 55.5 ± 25.5 | 53.3 ± 8.3 | 43.0 | - | 0.804 |
External rotation | 17 | 19 | 0 | 0 |
|
Preoperative | 19.4 ± 9.9 | 11.2 ± 6.1 | - | - | 0.005 |
Postoperative | 34.1 ± 13.3 | 19.3 ± 8.9 | - | - | <0.001 |
Change | +14.7 ± 13.2 | +8.1 ± 8.5 | - | - | 0.079 |
Continue to: DISCUSSION...
DISCUSSION
RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.
RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.10 This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.11 Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.16,17 Frankle and colleagues16 evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues17 evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).
It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.18 Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.19 However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.20
Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.6,21,22
One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.23 This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.26 However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.27 With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.
LIMITATIONS
Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.
CONCLUSION
The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.
This paper will be judged for the Resident Writer’s Award.
1. Boileau P, Moineau G, Roussanne Y, O'Shea K. Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469(9):2558-2567. doi:10.1007/s11999-011-1775-4.
2. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4,500 patients. J Orthop Trauma. 2014;29(1):54-59.
3. Cazeneuve JF, Cristofari DJ. Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up. Orthop Traumatol Surg Res. 2014;100(1):93-97. doi:10.1016/j.otsr.2013.12.005.
4. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41. doi:10.1016/j.jse.2011.04.009.
5. De Biase CF, Delcogliano M, Borroni M, Castagna A. Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere. Musculoskelet Surg. 2012;96(suppl 1):S27-SS34. doi:10.1007/s12306-012-0193-4.
6. Al-Hadithy N, Domos P, Sewell MD, Pandit R. Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years. J Shoulder Elbow Surg. 2014;23(11):1662-1668. doi:10.1016/j.jse.2014.03.001.
7. Ross M, Hope B, Stokes A, Peters SE, McLeod I, Duke PF. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015;24(2):215-222. doi:10.1016/j.jse.2014.05.022.
8. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544-2556. doi:10.2106/JBJS.I.00912.
9. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2015;24(6):988-993. doi:10.1016/j.jse.2015.01.001.
10. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(1):91-97. doi:10.1016/j.jse.2014.08.026.
11. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.
12. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. doi:10.1016/j.jclinepi.2009.06.006.
13. University of York Centre for Reviews and Dissemination, National Institute for Health Research. PROSPERO International prospective register of systematic reviews. University of York Web site. http://www.crd.york.ac.uk/PROSPERO/. Accessed November 1, 2016.
14. Oxford Centre for Evidence-based Medicine – Levels of evidence (March 2009). University of Oxford Web site: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed November 1, 2016.
15. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699. doi:10.2106/JBJS.F.00858.
16. Frankle M, Levy JC, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 2):178-190. doi:10.2106/JBJS.F.00123.
17. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486. doi:10.2106/JBJS.D.02342.
18. Peppers TA, Jobe CM, Dai QG, Williams PA, Libanati C. Fixation of humeral prostheses and axial micromotion. J Shoulder Elbow Surg. 1998;7(4):414-418. doi:10.1016/S1058-2746(98)90034-9.
19. Wiater JM, Moravek JE Jr, Budge MD, Koueiter DM, Marcantonio D, Wiater BP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214. doi:10.1016/j.jse.2013.11.032.
20. Nowinski RJ, Gillespie RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. J Shoulder Elbow Surg. 2012;21(3):324-328. doi:10.1016/j.jse.2011.08.072.
21. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y.
22. Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57-61. doi:10.1302/0301-620X.93B1.24218.
23. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467. doi:10.1016/j.jse.2014.08.016.
24. Coe MP, Greiwe RM, Joshi R, et al. The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012;21(10):1278-1288. doi:10.1016/j.jse.2011.10.010.
25. Renfree KJ, Hattrup SJ, Chang YH. Cost utility analysis of reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(12):1656-1661. doi:10.1016/j.jse.2013.08.002.
26. Chalmers PN, Slikker W, 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204. doi:10.1016/j.jse.2013.07.044.
27. Steen BM, Cabezas AF, Santoni BG, et al. Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg. 2015;24(9):1433-1441. doi:10.1016/j.jse.2015.01.005.
1. Boileau P, Moineau G, Roussanne Y, O'Shea K. Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469(9):2558-2567. doi:10.1007/s11999-011-1775-4.
2. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4,500 patients. J Orthop Trauma. 2014;29(1):54-59.
3. Cazeneuve JF, Cristofari DJ. Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up. Orthop Traumatol Surg Res. 2014;100(1):93-97. doi:10.1016/j.otsr.2013.12.005.
4. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41. doi:10.1016/j.jse.2011.04.009.
5. De Biase CF, Delcogliano M, Borroni M, Castagna A. Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere. Musculoskelet Surg. 2012;96(suppl 1):S27-SS34. doi:10.1007/s12306-012-0193-4.
6. Al-Hadithy N, Domos P, Sewell MD, Pandit R. Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years. J Shoulder Elbow Surg. 2014;23(11):1662-1668. doi:10.1016/j.jse.2014.03.001.
7. Ross M, Hope B, Stokes A, Peters SE, McLeod I, Duke PF. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015;24(2):215-222. doi:10.1016/j.jse.2014.05.022.
8. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544-2556. doi:10.2106/JBJS.I.00912.
9. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2015;24(6):988-993. doi:10.1016/j.jse.2015.01.001.
10. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(1):91-97. doi:10.1016/j.jse.2014.08.026.
11. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.
12. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. doi:10.1016/j.jclinepi.2009.06.006.
13. University of York Centre for Reviews and Dissemination, National Institute for Health Research. PROSPERO International prospective register of systematic reviews. University of York Web site. http://www.crd.york.ac.uk/PROSPERO/. Accessed November 1, 2016.
14. Oxford Centre for Evidence-based Medicine – Levels of evidence (March 2009). University of Oxford Web site: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed November 1, 2016.
15. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699. doi:10.2106/JBJS.F.00858.
16. Frankle M, Levy JC, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 2):178-190. doi:10.2106/JBJS.F.00123.
17. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486. doi:10.2106/JBJS.D.02342.
18. Peppers TA, Jobe CM, Dai QG, Williams PA, Libanati C. Fixation of humeral prostheses and axial micromotion. J Shoulder Elbow Surg. 1998;7(4):414-418. doi:10.1016/S1058-2746(98)90034-9.
19. Wiater JM, Moravek JE Jr, Budge MD, Koueiter DM, Marcantonio D, Wiater BP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214. doi:10.1016/j.jse.2013.11.032.
20. Nowinski RJ, Gillespie RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. J Shoulder Elbow Surg. 2012;21(3):324-328. doi:10.1016/j.jse.2011.08.072.
21. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y.
22. Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57-61. doi:10.1302/0301-620X.93B1.24218.
23. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467. doi:10.1016/j.jse.2014.08.016.
24. Coe MP, Greiwe RM, Joshi R, et al. The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012;21(10):1278-1288. doi:10.1016/j.jse.2011.10.010.
25. Renfree KJ, Hattrup SJ, Chang YH. Cost utility analysis of reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(12):1656-1661. doi:10.1016/j.jse.2013.08.002.
26. Chalmers PN, Slikker W, 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204. doi:10.1016/j.jse.2013.07.044.
27. Steen BM, Cabezas AF, Santoni BG, et al. Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg. 2015;24(9):1433-1441. doi:10.1016/j.jse.2015.01.005.
TAKE-HOME POINTS
- RTSA is an effective treatment for rotator cuff tear arthropathy (the most common reason patients undergo RTSA).
- While there has been a plethora of literature surrounding outcomes of RTSA over the past several years, the methodological quality of this literature has been limited.
- Similarly, this study found the number of publications surrounding RTSA is increasing each year while the average methodological quality of these studies is decreasing.
- Females undergo RTSA more commonly than males, and the average age of patients undergoing RTSA is 71 years.
- Interestingly, patients’ postoperative external rotation was higher in studies out of North America compared to other continents. Further research into this area is needed to understand more about this finding.
Management of Isolated Greater Tuberosity Fractures: A Systematic Review
Take-Home Points
- Fractures of the greater tuberosity are often mismanaged.
- Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
- Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
- Stiffness is the most common postoperative complication.
- Surgery is associated with high patient satisfaction and low rates of complications and reoperations.
Although proximal humerus fractures are common in the elderly, isolated fractures of the greater tuberosity occur less often. Management depends on several factors, including fracture pattern and displacement.1,2 Nondisplaced fractures are often successfully managed with sling immobilization and early range of motion.3,4 Although surgical intervention improves outcomes in displaced greater tuberosity fractures, the ideal surgical treatment is less clear.5
Displaced greater tuberosity fractures may require surgery for prevention of subacromial impingement and range-of-motion deficits.2 Superior fracture displacement results in decreased shoulder abduction, and posterior displacement can limit external rotation.6 Although the greater tuberosity can displace in any direction, posterosuperior displacement has the worst outcomes.1 The exact surgery-warranting displacement amount ranges from 3 mm to 10 mm but is yet to be clearly elucidated.5,6 Less displacement is tolerated by young overhead athletes, and more displacement by older less active patients.5,7,8 Surgical options for isolated greater tuberosity fractures include fragment excision, open reduction and internal fixation (ORIF), closed reduction with percutaneous fixation, and arthroscopically assisted reduction with internal fixation.3,9,10
We conducted a study to determine the management patterns for isolated greater tuberosity fractures. We hypothesized that greater tuberosity fractures displaced <5 mm may be managed nonoperatively and that greater tuberosity fractures displaced >5 mm require surgical fixation.
Methods
Search Strategy
We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist11 and registered it (CRD42014010691) with the PROSPERO international prospective register of systematic reviews. Literature searches using the PubMed/Medline database and the Cochrane Central Register of Clinical Trials were completed in August 2014. There were no date or year restrictions. Key words were used to capture all English- language studies with level I to IV evidence (Oxford Centre for Evidence-Based Medicine) and reported clinical or radiographic outcomes. Initial exclusion criteria were cadaveric, biomechanical, histologic, and kinematic results. An electronic search algorithm with key words and a series of NOT phrases was designed to match our exclusion criteria:
((((((((((((((((((((((((((((((((((((((((((((((((((greater[Title/Abstract]) AND tuberosity [Title/Abstract] OR tubercle [Title/Abstract]) AND fracture[Title/Abstract]) AND proximal[Title/Abstract] AND (English[lang]))) NOT intramedullary[Title] AND (English[lang]))) NOT nonunion[Title] AND (English[lang]))) NOT malunion[Title] AND (English[lang]))) NOT biomechanical[Title/Abstract] AND (English[lang]))) NOT cadaveric[Title/Abstract] AND (English[lang]))) NOT cadaver[Title/Abstract] AND (English[lang]))) NOT ((basic[Title/Abstract]) AND science[Title/Abstract] AND (English[lang])) AND (English[lang]))) NOT revision[Title] AND (English[lang]))) NOT pediatric[Title] AND (English[lang]))) NOT physeal[Title] AND (English[lang]))) NOT children[Title] AND (English[lang]))) NOT instability[Title] AND (English[lang]))) NOT imaging[Title])) NOT salter[Title])) NOT physis[Title])) NOT shaft[Title])) NOT distal[Title])) NOT clavicle[Title])) NOT scapula[Title])) NOT ((diaphysis[Title]) AND diaphyseal[Title]))) NOT infection[Title])) NOT laboratory[Title/Abstract])) NOT metastatic[Title/Abstract])) NOT (((((((malignancy[Title/Abstract]) OR malignant[Title/Abstract]) OR tumor[Title/Abstract]) OR oncologic[Title/Abstract]) OR cyst[Title/Abstract]) OR aneurysmal[Title/Abstract]) OR unicameral[Title/Abstract]).
Study Selection
We obtained 135 search results and reviewed them for further differentiation. All the references in these studies were cross-referenced for inclusion (if missed by the initial search), which added another 15 studies. Technical notes, letters to the editor, and level V evidence reviews were excluded. Double-counting of patients was avoided by comparing each study’s authors, data collection period, and ethnic population with those of the other studies. In cases of overlapping authorship, period, or place, only the study with the longer follow-up, more patients, or more comprehensive data was included. For studies separating outcomes by diagnosis, only outcomes of isolated greater tuberosity fractures were included. Data on 3- or 4-part proximal humerus fractures and isolated lesser tuberosity fractures were excluded. Studies that could not be deconstructed as such or that were devoted solely to one of our exclusion criteria were excluded. Minimum follow-up was 2 years. After all inclusion and exclusion criteria were accounted for, 13 studies with 429 patients (429 shoulders) were selected for inclusion (Figure, Table 1).2,5,12-22
Data Extraction
We extracted data from the 13 studies that met the eligibility criteria. Details of study design, sample size, and patient demographics, including age, sex, and hand dominance, were recorded, as were mechanism of injury and concomitant anterior shoulder instability. To capture the most patients, we noted radiographic fracture displacement categorically rather than continuously; patients were divided into 2 displacement groups (<5 mm, >5 mm). Most studies did not define degree of comminution or specific direction of displacement per fracture, so these variables were not included in the data analysis. Nonoperative management and operative management were studied. We abstracted surgical factors, such as approach, method, fixation type (screws or sutures), and technique (suture anchors or transosseous tunnels). Clinical outcomes included physical examination findings, functional assessment results (patient satisfaction; Constant and University of California Los Angeles [UCLA] shoulder scores), and the number of revisions. Radiologic outcomes, retrieved from radiographs or computed tomography scans, focused on loss of reduction (as determined by the respective authors), malunion, nonunion, and heterotopic ossification. Each study’s methodologic quality and bias were evaluated with the 15-item Modified Coleman Methodology Score (MCMS), which was described by Cowan and colleagues.23 The MCMS has been used to assess randomized and nonrandomized patient trials.24,25 Its scaled potential score ranges from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor).
Statistical Analysis
We report our data as weighted means (SDs). A mean was calculated for each study that reported a respective data point, and each mean was then weighed according to its study sample size. This calculation was performed by multiplying a study’s individual mean by the number of patients enrolled in that study and dividing the sum of these weighted data points by the number of eligible patients in all relevant studies. The result was that the nonweighted means from studies with smaller sample sizes did not carry as much weight as the nonweighted means from larger studies. We compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic). Regarding all patient, surgery, and outcomes data, unpaired Student t tests were used for continuous variables and 2-tailed Fisher exact tests for categorical variables with α = 0.05 (SPSS Version 18; IBM).
Results
Demographic information and treatment strategies are listed in Table 2. Fifty-eight percent of patients were male, 59.0% of dominant shoulders were affected, and 59.2% of fractures were displaced <5 mm. Concomitant shoulder instability was reported in 28.1% of patients. Mechanism of injury was not reported in all studies but most commonly (n = 75; 49.3%) involved a fall on an outstretched hand; 31 patients (20.4%) had a sports-related injury, and another 37 (24.3%) were injured in a motor vehicle collision. Of the 429 patients, 217 (50.6%) were treated nonoperatively, and 212 (49.4%) underwent surgery. Open, arthroscopic, and percutaneous approaches were reported. No studies presented outcomes of fragment excision.
Postoperative physical examination findings were underreported so that surgical groups could be compared. Of all the surgical studies, 4 reported postoperative forward elevation (mean, 160°; SD, 9.8°) and external rotation (mean, 46.4°; SD 26.3°).14,15,18,22 No malunions and only 1 nonunion were reported in all 13 studies. No deaths or other serious medical complications were reported. Patients with anterior instability more often underwent surgery than were treated nonoperatively (39.2% vs 12.0%; P < .01) and more often had fractures displaced >5 mm than <5 mm (44.3% vs 14.5%; P < .01).
Comparisons of treatment type are listed in Table 3. Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (P < .01) and better patient satisfaction (P < .01). Operative patients had a significantly higher rate of shoulder stiffness (P < .01). Eight operative patients (3.8%) and no nonoperative patients required reoperation during clinical follow-up (P < .01). All 12 reported cases of stiffness were in the operative group, and 3 required revision surgery. One patient required revision ORIF. There were 2 cases of postoperative superficial infection (0.9%) and 4 neurologic injuries (1.9%).
Comparisons of displacement amount are listed in Table 4. Compared with fractures displaced >5 mm, those displaced <5 mm had more radiographic losses of reduction (P < .01) but fewer instances of heterotopic ossification (P < .01). Fractures displaced >5 mm were significantly more likely than not to be managed with surgery (P < .01) and significantly more likely to develop stiffness after treatment (P = .01). One patient (0.4%) with a fracture displaced <5 mm eventually underwent surgery for stiffness, and 6 patients (3.6%) with fractures displaced >5 mm required reoperation (P = .02).
Comparisons of surgery type are listed in Table 5. All open procedures were performed with a deltoid-splitting approach. Screw fixation was used in 4 cases: 2 percutaneous5,21 and 2 open.2,5 The other open and arthroscopic studies described suture fixation, half with anchors (77/156 patients; 49.4%) and half with transosseous tunnels (79/156; 50.6%). There were no statistically significant differences between open/percutaneous and arthroscopic techniques in terms of stiffness, superficial infection, neurologic injury, or reoperation rate.
Fisher exact tests were used to perform isolated comparisons of screws and sutures as well as suture anchors and transosseous tunnels. Patients with screw fixation were significantly (P = .051) less likely to require reoperation (0/56; 0%) than patients with suture fixation (8/100; 8.0%). Screw fixation also led to significantly less stiffness (0% vs 12.0%; P < .01) but trended toward a higher rate of superficial infection (3.6% vs 0%; P = .13). There was no statistical difference in nerve injury rates between screws and sutures (1.8% vs 3.0%; P = 1.0). There were no significant differences in reoperations, stiffness, superficial infections, or nerve injuries between suture anchor and transosseous tunnel constructs.
For all 13 studies, mean (SD) MCMS was 41.1 (8.6).
Discussion
Five percent of all fractures involve the proximal humerus, and 20% of proximal humerus fractures are isolated greater tuberosity fractures.26,27 In his classic 1970 article, Neer6 formulated the 4-part proximal humerus fracture classification and defined greater tuberosity fracture “parts” using the same criteria as for other fracture “parts.” Neer6 recommended nonoperative management for isolated greater tuberosity fractures displaced <1 cm but did not present evidence corroborating his recommendation. More recent cutoffs for nonoperative management include 5 mm (general population) and 3 mm (athletes).7,17
In the present systematic review of greater tuberosity fractures, 3 separate comparisons were made: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).
Treatment Type. Only 4 studies reported data on nonoperative treatment outcomes.5,12,16,17 Of these 4 studies, 2 found successful outcomes for fractures displaced <5 mm.12,17 Platzer and colleagues17 found good or excellent results in 97% of 135 shoulders after 4 years. Good results were defined with shoulder scores of ≥80 (Constant), <8 (Vienna), and >28 (UCLA), and excellent results were defined with maximum scores on 2 of the 3 systems. Platzer and colleagues17 also found nonsignificantly worse shoulder scores with superior displacement of 3 mm to 5 mm and recommended surgery for overhead athletes in this group. Rath and colleagues12 described a successful 3-phase rehabilitation protocol of sling immobilization for 3 weeks, pendulum exercises for 3 weeks, and active exercises thereafter. By an average of 31 months, patient satisfaction scores improved to 9.5 from 4.2 (10-point scale), though the authors cautioned that pain and decreased motion lasted 8 months on average. Conservative treatment was far less successful in the 2 studies of fractures displaced >5 mm.5,16 Keene and colleagues16 reported unsatisfactory results in all 4 patients with fractures displaced >1.5 cm. In a study separate from their 2005 analysis,17 Platzer and colleagues5 in 2008 evaluated displaced fractures and found function and patient satisfaction were inferior after nonoperative treatment than after surgery. The studies by Keene and colleagues16 and Platzer and colleagues5 support the finding of an overall lower patient satisfaction rate in nonoperative patients.
Fracture Displacement Amount. Only 2 arthroscopic studies and no open studies addressed surgery for fractures displaced <5 mm. Fewer than 16% of these fractures were managed operatively, and <1% required reoperation. By contrast, almost all fractures displaced >5 mm were managed operatively, and 3.6% required reoperation. Radiographic loss of reduction was more common in fractures displaced <5 mm, primarily because they were managed without fixation. Radiographic loss of reduction was reported in only 9 operatively treated patients, none of whom was symptomatic enough to require another surgery.5 Reoperations were most commonly performed for stiffness, which itself was significantly more common in fractures displaced >5 mm. Bhatia and colleagues14 reported the highest reoperation rate (14.3%; 3/21), but they studied more complex, comminuted fractures of the greater tuberosity. Two of their 3 reoperations were biceps tenodeses for inflamed, stiff tenosynovitis, and the third patient had a foreign body giant cell reaction to suture material. Fewer than 1% of patients with operatively managed displaced fractures required revision ORIF, and <2% developed a superficial infection or postoperative nerve palsy.19,22 For displaced greater tuberosity fractures, surgery is highly successful overall, complication rates are very low, and 90% of patients report being satisfied.
Surgery Type. Patients were divided into 2 groups. In the nonarthroscopic group, open and percutaneous approaches were used. All studies that described a percutaneous approach used screw fixation5,21; in addition, 32 patients were treated with screws through an open approach.2,5 The other open and arthroscopic studies used suture fixation. Interestingly, no studies reported on clinical outcomes of fragment excision. There were no statistically significant differences in rates of reoperation, stiffness, infection, or neurologic injury between the arthroscopic and nonarthroscopic groups. Patient satisfaction scores were slightly higher in the nonarthroscopic group (91.0% vs 87.8%), but the difference was not statistically significant.
With surgical techniques isolated, there were no significant differences between suture anchors and transosseous tunnel constructs, but screws performed significantly better than suture techniques. Compared with suture fixation, screw fixation led to significantly fewer cases of stiffness and reoperation, which suggests surgeons need to give screws more consideration in the operative management of these fractures. However, the number of patients treated with screws was smaller than the number treated with suture fixation; it is possible the differences between these cohorts would be eliminated if there were more patients in the screw cohort. In addition, screw fixation was universally performed with an open or percutaneous approach and trended toward a higher infection rate. As screw and suture techniques have low rates of complications and reoperations, we recommend leaving fixation choice to the surgeon.
Anterior shoulder instability has been associated with greater tuberosity fractures.1,8,19 The supraspinatus, infraspinatus, and teres minor muscles all insert into the greater tuberosity and resist anterior translation of the proximal humerus. Loss of this dynamic muscle stabilization is amplified by tuberosity fracture displacement: Anterior shoulder instability was significantly more common in fractures displaced >5 mm (44.3%) vs <5 mm (14.5%). In turn, glenohumeral instability was more common in patients treated with surgery, specifically open surgery, because displaced fractures may not be as easily accessed with arthroscopic techniques. No studies reported concomitant labral repair or capsular plication techniques.
This systematic review was limited by the studies analyzed. All but 1 study5 had level IV evidence. Mean (SD) MCMS was 41.8 (8.6). Any MCMS score <54 indicates a poor methodology level, but this scoring system is designed for randomized controlled trials,23 and there were none in this study. Physical examination findings, such as range of motion, were underreported. In addition, radiographic parameters were not consistently described but rather were determined by the respective authors’ subjective interpretations of malunion, nonunion, and loss of reduction. Publication bias is present in that we excluded non- English language studies and medical conference abstracts and may have omitted potentially eligible studies not discoverable with our search methodology. Performance bias is a factor in any systematic review with multiple surgeons and wide variation in surgical technique.
Conclusion
Greater tuberosity fractures displaced <5 mm may be safely managed nonoperatively, as there are no reports of nonoperatively managed fractures that subsequently required surgery. Nonoperative treatment was initially associated with low patient satisfaction, but only because displaced fractures were conservatively managed in early studies.5,16 Fractures displaced >5 mm respond well to operative fixation with screws, suture anchors, or transosseous suture tunnels. Stiffness is the most common postoperative complication (<6%), followed by heterotopic ossification, transient neurapraxias, and superficial infection. There are no discernible differences in outcome between open and arthroscopic techniques, but screw fixation may lead to significantly fewer cases of stiffness and reoperation in comparison with suture constructs.
1. Verdano MA, Aliani D, Pellegrini A, Baudi P, Pedrazzi G, Ceccarelli F. Isolated fractures of the greater tuberosity in proximal humerus: does the direction of displacement influence functional outcome? An analysis of displacement in greater tuberosity fractures. Acta Biomed. 2013;84(3):219-228.
2. Yin B, Moen TC, Thompson SA, Bigliani LU, Ahmad CS, Levine WN. Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes. Orthopedics. 2012;35(6):e807-e814.
3. Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12(6):641-649.
4. Norouzi M, Naderi MN, Komasi MH, Sharifzadeh SR, Shahrezaei M, Eajazi A. Clinical results of using the proximal humeral internal locking system plate for internal fixation of displaced proximal humeral fractures. Am J Orthop. 2012;41(5):E64-E68.
5. Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma. 2008;65(4):843-848.
6. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
7. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Jt Dis. 1997;56(3):171-176.
8. McLaughlin HL. Dislocation of the shoulder with tuberosity fracture. Surg Clin North Am. 1963;43:1615-1620.
9. DeBottis D, Anavian J, Green A. Surgical management of isolated greater tuberosity fractures of the proximal humerus. Orthop Clin North Am. 2014;45(2):207-218.
10. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong). 2009;17(2):142-145.
11. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.
12. Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elbow Surg. 2013;22(10):e8-e11.
13. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am. 2007;89(8):1700-1709.
14. Bhatia DN, van Rooyen KS, Toit du DF, de Beer JF. Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results. Injury. 2006;37(10):946-952.
15. Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991;73(8):1213-1218.
16. Keene JS, Huizenga RE, Engber WD, Rogers SC. Proximal humeral fractures: a correlation of residual deformity with long-term function. Orthopedics. 1983;6(2):173-178.
17. Platzer P, Kutscha-Lissberg F, Lehr S, Vecsei V, Gaebler C. The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity. Injury. 2005;36(10):1185-1189.
18. Park SE, Ji JH, Shafi M, Jung JJ, Gil HJ, Lee HH. Arthroscopic management of occult greater tuberosity fracture of the shoulder. Eur J Orthop Surg Traumatol. 2014;24(4):475-482.
19. Dimakopoulos P, Panagopoulos A, Kasimatis G, Syggelos SA, Lambiris E. Anterior traumatic shoulder dislocation associated with displaced greater tuberosity fracture: the necessity of operative treatment. J Orthop Trauma. 2007;21(2):104-112.
20. Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy. 2000;16(7):695-700.
21. Chen CY, Chao EK, Tu YK, Ueng SW, Shih CH. Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma. 1998;45(6):1039-1045.
22. Ji JH, Shafi M, Song IS, Kim YY, McFarland EG, Moon CY. Arthroscopic fixation technique for comminuted, displaced greater tuberosity fracture. Arthroscopy. 2010;26(5):600-609.
23. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.
24. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. 2010;92(12):2220-2233.
25. Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation—a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791.
26. Chun JM, Groh GI, Rockwood CA. Two-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1994;3(5):273-287.
27. Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humeral: current concepts. Injury. 2008;39(3):284-298.
Take-Home Points
- Fractures of the greater tuberosity are often mismanaged.
- Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
- Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
- Stiffness is the most common postoperative complication.
- Surgery is associated with high patient satisfaction and low rates of complications and reoperations.
Although proximal humerus fractures are common in the elderly, isolated fractures of the greater tuberosity occur less often. Management depends on several factors, including fracture pattern and displacement.1,2 Nondisplaced fractures are often successfully managed with sling immobilization and early range of motion.3,4 Although surgical intervention improves outcomes in displaced greater tuberosity fractures, the ideal surgical treatment is less clear.5
Displaced greater tuberosity fractures may require surgery for prevention of subacromial impingement and range-of-motion deficits.2 Superior fracture displacement results in decreased shoulder abduction, and posterior displacement can limit external rotation.6 Although the greater tuberosity can displace in any direction, posterosuperior displacement has the worst outcomes.1 The exact surgery-warranting displacement amount ranges from 3 mm to 10 mm but is yet to be clearly elucidated.5,6 Less displacement is tolerated by young overhead athletes, and more displacement by older less active patients.5,7,8 Surgical options for isolated greater tuberosity fractures include fragment excision, open reduction and internal fixation (ORIF), closed reduction with percutaneous fixation, and arthroscopically assisted reduction with internal fixation.3,9,10
We conducted a study to determine the management patterns for isolated greater tuberosity fractures. We hypothesized that greater tuberosity fractures displaced <5 mm may be managed nonoperatively and that greater tuberosity fractures displaced >5 mm require surgical fixation.
Methods
Search Strategy
We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist11 and registered it (CRD42014010691) with the PROSPERO international prospective register of systematic reviews. Literature searches using the PubMed/Medline database and the Cochrane Central Register of Clinical Trials were completed in August 2014. There were no date or year restrictions. Key words were used to capture all English- language studies with level I to IV evidence (Oxford Centre for Evidence-Based Medicine) and reported clinical or radiographic outcomes. Initial exclusion criteria were cadaveric, biomechanical, histologic, and kinematic results. An electronic search algorithm with key words and a series of NOT phrases was designed to match our exclusion criteria:
((((((((((((((((((((((((((((((((((((((((((((((((((greater[Title/Abstract]) AND tuberosity [Title/Abstract] OR tubercle [Title/Abstract]) AND fracture[Title/Abstract]) AND proximal[Title/Abstract] AND (English[lang]))) NOT intramedullary[Title] AND (English[lang]))) NOT nonunion[Title] AND (English[lang]))) NOT malunion[Title] AND (English[lang]))) NOT biomechanical[Title/Abstract] AND (English[lang]))) NOT cadaveric[Title/Abstract] AND (English[lang]))) NOT cadaver[Title/Abstract] AND (English[lang]))) NOT ((basic[Title/Abstract]) AND science[Title/Abstract] AND (English[lang])) AND (English[lang]))) NOT revision[Title] AND (English[lang]))) NOT pediatric[Title] AND (English[lang]))) NOT physeal[Title] AND (English[lang]))) NOT children[Title] AND (English[lang]))) NOT instability[Title] AND (English[lang]))) NOT imaging[Title])) NOT salter[Title])) NOT physis[Title])) NOT shaft[Title])) NOT distal[Title])) NOT clavicle[Title])) NOT scapula[Title])) NOT ((diaphysis[Title]) AND diaphyseal[Title]))) NOT infection[Title])) NOT laboratory[Title/Abstract])) NOT metastatic[Title/Abstract])) NOT (((((((malignancy[Title/Abstract]) OR malignant[Title/Abstract]) OR tumor[Title/Abstract]) OR oncologic[Title/Abstract]) OR cyst[Title/Abstract]) OR aneurysmal[Title/Abstract]) OR unicameral[Title/Abstract]).
Study Selection
We obtained 135 search results and reviewed them for further differentiation. All the references in these studies were cross-referenced for inclusion (if missed by the initial search), which added another 15 studies. Technical notes, letters to the editor, and level V evidence reviews were excluded. Double-counting of patients was avoided by comparing each study’s authors, data collection period, and ethnic population with those of the other studies. In cases of overlapping authorship, period, or place, only the study with the longer follow-up, more patients, or more comprehensive data was included. For studies separating outcomes by diagnosis, only outcomes of isolated greater tuberosity fractures were included. Data on 3- or 4-part proximal humerus fractures and isolated lesser tuberosity fractures were excluded. Studies that could not be deconstructed as such or that were devoted solely to one of our exclusion criteria were excluded. Minimum follow-up was 2 years. After all inclusion and exclusion criteria were accounted for, 13 studies with 429 patients (429 shoulders) were selected for inclusion (Figure, Table 1).2,5,12-22
Data Extraction
We extracted data from the 13 studies that met the eligibility criteria. Details of study design, sample size, and patient demographics, including age, sex, and hand dominance, were recorded, as were mechanism of injury and concomitant anterior shoulder instability. To capture the most patients, we noted radiographic fracture displacement categorically rather than continuously; patients were divided into 2 displacement groups (<5 mm, >5 mm). Most studies did not define degree of comminution or specific direction of displacement per fracture, so these variables were not included in the data analysis. Nonoperative management and operative management were studied. We abstracted surgical factors, such as approach, method, fixation type (screws or sutures), and technique (suture anchors or transosseous tunnels). Clinical outcomes included physical examination findings, functional assessment results (patient satisfaction; Constant and University of California Los Angeles [UCLA] shoulder scores), and the number of revisions. Radiologic outcomes, retrieved from radiographs or computed tomography scans, focused on loss of reduction (as determined by the respective authors), malunion, nonunion, and heterotopic ossification. Each study’s methodologic quality and bias were evaluated with the 15-item Modified Coleman Methodology Score (MCMS), which was described by Cowan and colleagues.23 The MCMS has been used to assess randomized and nonrandomized patient trials.24,25 Its scaled potential score ranges from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor).
Statistical Analysis
We report our data as weighted means (SDs). A mean was calculated for each study that reported a respective data point, and each mean was then weighed according to its study sample size. This calculation was performed by multiplying a study’s individual mean by the number of patients enrolled in that study and dividing the sum of these weighted data points by the number of eligible patients in all relevant studies. The result was that the nonweighted means from studies with smaller sample sizes did not carry as much weight as the nonweighted means from larger studies. We compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic). Regarding all patient, surgery, and outcomes data, unpaired Student t tests were used for continuous variables and 2-tailed Fisher exact tests for categorical variables with α = 0.05 (SPSS Version 18; IBM).
Results
Demographic information and treatment strategies are listed in Table 2. Fifty-eight percent of patients were male, 59.0% of dominant shoulders were affected, and 59.2% of fractures were displaced <5 mm. Concomitant shoulder instability was reported in 28.1% of patients. Mechanism of injury was not reported in all studies but most commonly (n = 75; 49.3%) involved a fall on an outstretched hand; 31 patients (20.4%) had a sports-related injury, and another 37 (24.3%) were injured in a motor vehicle collision. Of the 429 patients, 217 (50.6%) were treated nonoperatively, and 212 (49.4%) underwent surgery. Open, arthroscopic, and percutaneous approaches were reported. No studies presented outcomes of fragment excision.
Postoperative physical examination findings were underreported so that surgical groups could be compared. Of all the surgical studies, 4 reported postoperative forward elevation (mean, 160°; SD, 9.8°) and external rotation (mean, 46.4°; SD 26.3°).14,15,18,22 No malunions and only 1 nonunion were reported in all 13 studies. No deaths or other serious medical complications were reported. Patients with anterior instability more often underwent surgery than were treated nonoperatively (39.2% vs 12.0%; P < .01) and more often had fractures displaced >5 mm than <5 mm (44.3% vs 14.5%; P < .01).
Comparisons of treatment type are listed in Table 3. Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (P < .01) and better patient satisfaction (P < .01). Operative patients had a significantly higher rate of shoulder stiffness (P < .01). Eight operative patients (3.8%) and no nonoperative patients required reoperation during clinical follow-up (P < .01). All 12 reported cases of stiffness were in the operative group, and 3 required revision surgery. One patient required revision ORIF. There were 2 cases of postoperative superficial infection (0.9%) and 4 neurologic injuries (1.9%).
Comparisons of displacement amount are listed in Table 4. Compared with fractures displaced >5 mm, those displaced <5 mm had more radiographic losses of reduction (P < .01) but fewer instances of heterotopic ossification (P < .01). Fractures displaced >5 mm were significantly more likely than not to be managed with surgery (P < .01) and significantly more likely to develop stiffness after treatment (P = .01). One patient (0.4%) with a fracture displaced <5 mm eventually underwent surgery for stiffness, and 6 patients (3.6%) with fractures displaced >5 mm required reoperation (P = .02).
Comparisons of surgery type are listed in Table 5. All open procedures were performed with a deltoid-splitting approach. Screw fixation was used in 4 cases: 2 percutaneous5,21 and 2 open.2,5 The other open and arthroscopic studies described suture fixation, half with anchors (77/156 patients; 49.4%) and half with transosseous tunnels (79/156; 50.6%). There were no statistically significant differences between open/percutaneous and arthroscopic techniques in terms of stiffness, superficial infection, neurologic injury, or reoperation rate.
Fisher exact tests were used to perform isolated comparisons of screws and sutures as well as suture anchors and transosseous tunnels. Patients with screw fixation were significantly (P = .051) less likely to require reoperation (0/56; 0%) than patients with suture fixation (8/100; 8.0%). Screw fixation also led to significantly less stiffness (0% vs 12.0%; P < .01) but trended toward a higher rate of superficial infection (3.6% vs 0%; P = .13). There was no statistical difference in nerve injury rates between screws and sutures (1.8% vs 3.0%; P = 1.0). There were no significant differences in reoperations, stiffness, superficial infections, or nerve injuries between suture anchor and transosseous tunnel constructs.
For all 13 studies, mean (SD) MCMS was 41.1 (8.6).
Discussion
Five percent of all fractures involve the proximal humerus, and 20% of proximal humerus fractures are isolated greater tuberosity fractures.26,27 In his classic 1970 article, Neer6 formulated the 4-part proximal humerus fracture classification and defined greater tuberosity fracture “parts” using the same criteria as for other fracture “parts.” Neer6 recommended nonoperative management for isolated greater tuberosity fractures displaced <1 cm but did not present evidence corroborating his recommendation. More recent cutoffs for nonoperative management include 5 mm (general population) and 3 mm (athletes).7,17
In the present systematic review of greater tuberosity fractures, 3 separate comparisons were made: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).
Treatment Type. Only 4 studies reported data on nonoperative treatment outcomes.5,12,16,17 Of these 4 studies, 2 found successful outcomes for fractures displaced <5 mm.12,17 Platzer and colleagues17 found good or excellent results in 97% of 135 shoulders after 4 years. Good results were defined with shoulder scores of ≥80 (Constant), <8 (Vienna), and >28 (UCLA), and excellent results were defined with maximum scores on 2 of the 3 systems. Platzer and colleagues17 also found nonsignificantly worse shoulder scores with superior displacement of 3 mm to 5 mm and recommended surgery for overhead athletes in this group. Rath and colleagues12 described a successful 3-phase rehabilitation protocol of sling immobilization for 3 weeks, pendulum exercises for 3 weeks, and active exercises thereafter. By an average of 31 months, patient satisfaction scores improved to 9.5 from 4.2 (10-point scale), though the authors cautioned that pain and decreased motion lasted 8 months on average. Conservative treatment was far less successful in the 2 studies of fractures displaced >5 mm.5,16 Keene and colleagues16 reported unsatisfactory results in all 4 patients with fractures displaced >1.5 cm. In a study separate from their 2005 analysis,17 Platzer and colleagues5 in 2008 evaluated displaced fractures and found function and patient satisfaction were inferior after nonoperative treatment than after surgery. The studies by Keene and colleagues16 and Platzer and colleagues5 support the finding of an overall lower patient satisfaction rate in nonoperative patients.
Fracture Displacement Amount. Only 2 arthroscopic studies and no open studies addressed surgery for fractures displaced <5 mm. Fewer than 16% of these fractures were managed operatively, and <1% required reoperation. By contrast, almost all fractures displaced >5 mm were managed operatively, and 3.6% required reoperation. Radiographic loss of reduction was more common in fractures displaced <5 mm, primarily because they were managed without fixation. Radiographic loss of reduction was reported in only 9 operatively treated patients, none of whom was symptomatic enough to require another surgery.5 Reoperations were most commonly performed for stiffness, which itself was significantly more common in fractures displaced >5 mm. Bhatia and colleagues14 reported the highest reoperation rate (14.3%; 3/21), but they studied more complex, comminuted fractures of the greater tuberosity. Two of their 3 reoperations were biceps tenodeses for inflamed, stiff tenosynovitis, and the third patient had a foreign body giant cell reaction to suture material. Fewer than 1% of patients with operatively managed displaced fractures required revision ORIF, and <2% developed a superficial infection or postoperative nerve palsy.19,22 For displaced greater tuberosity fractures, surgery is highly successful overall, complication rates are very low, and 90% of patients report being satisfied.
Surgery Type. Patients were divided into 2 groups. In the nonarthroscopic group, open and percutaneous approaches were used. All studies that described a percutaneous approach used screw fixation5,21; in addition, 32 patients were treated with screws through an open approach.2,5 The other open and arthroscopic studies used suture fixation. Interestingly, no studies reported on clinical outcomes of fragment excision. There were no statistically significant differences in rates of reoperation, stiffness, infection, or neurologic injury between the arthroscopic and nonarthroscopic groups. Patient satisfaction scores were slightly higher in the nonarthroscopic group (91.0% vs 87.8%), but the difference was not statistically significant.
With surgical techniques isolated, there were no significant differences between suture anchors and transosseous tunnel constructs, but screws performed significantly better than suture techniques. Compared with suture fixation, screw fixation led to significantly fewer cases of stiffness and reoperation, which suggests surgeons need to give screws more consideration in the operative management of these fractures. However, the number of patients treated with screws was smaller than the number treated with suture fixation; it is possible the differences between these cohorts would be eliminated if there were more patients in the screw cohort. In addition, screw fixation was universally performed with an open or percutaneous approach and trended toward a higher infection rate. As screw and suture techniques have low rates of complications and reoperations, we recommend leaving fixation choice to the surgeon.
Anterior shoulder instability has been associated with greater tuberosity fractures.1,8,19 The supraspinatus, infraspinatus, and teres minor muscles all insert into the greater tuberosity and resist anterior translation of the proximal humerus. Loss of this dynamic muscle stabilization is amplified by tuberosity fracture displacement: Anterior shoulder instability was significantly more common in fractures displaced >5 mm (44.3%) vs <5 mm (14.5%). In turn, glenohumeral instability was more common in patients treated with surgery, specifically open surgery, because displaced fractures may not be as easily accessed with arthroscopic techniques. No studies reported concomitant labral repair or capsular plication techniques.
This systematic review was limited by the studies analyzed. All but 1 study5 had level IV evidence. Mean (SD) MCMS was 41.8 (8.6). Any MCMS score <54 indicates a poor methodology level, but this scoring system is designed for randomized controlled trials,23 and there were none in this study. Physical examination findings, such as range of motion, were underreported. In addition, radiographic parameters were not consistently described but rather were determined by the respective authors’ subjective interpretations of malunion, nonunion, and loss of reduction. Publication bias is present in that we excluded non- English language studies and medical conference abstracts and may have omitted potentially eligible studies not discoverable with our search methodology. Performance bias is a factor in any systematic review with multiple surgeons and wide variation in surgical technique.
Conclusion
Greater tuberosity fractures displaced <5 mm may be safely managed nonoperatively, as there are no reports of nonoperatively managed fractures that subsequently required surgery. Nonoperative treatment was initially associated with low patient satisfaction, but only because displaced fractures were conservatively managed in early studies.5,16 Fractures displaced >5 mm respond well to operative fixation with screws, suture anchors, or transosseous suture tunnels. Stiffness is the most common postoperative complication (<6%), followed by heterotopic ossification, transient neurapraxias, and superficial infection. There are no discernible differences in outcome between open and arthroscopic techniques, but screw fixation may lead to significantly fewer cases of stiffness and reoperation in comparison with suture constructs.
Take-Home Points
- Fractures of the greater tuberosity are often mismanaged.
- Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
- Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
- Stiffness is the most common postoperative complication.
- Surgery is associated with high patient satisfaction and low rates of complications and reoperations.
Although proximal humerus fractures are common in the elderly, isolated fractures of the greater tuberosity occur less often. Management depends on several factors, including fracture pattern and displacement.1,2 Nondisplaced fractures are often successfully managed with sling immobilization and early range of motion.3,4 Although surgical intervention improves outcomes in displaced greater tuberosity fractures, the ideal surgical treatment is less clear.5
Displaced greater tuberosity fractures may require surgery for prevention of subacromial impingement and range-of-motion deficits.2 Superior fracture displacement results in decreased shoulder abduction, and posterior displacement can limit external rotation.6 Although the greater tuberosity can displace in any direction, posterosuperior displacement has the worst outcomes.1 The exact surgery-warranting displacement amount ranges from 3 mm to 10 mm but is yet to be clearly elucidated.5,6 Less displacement is tolerated by young overhead athletes, and more displacement by older less active patients.5,7,8 Surgical options for isolated greater tuberosity fractures include fragment excision, open reduction and internal fixation (ORIF), closed reduction with percutaneous fixation, and arthroscopically assisted reduction with internal fixation.3,9,10
We conducted a study to determine the management patterns for isolated greater tuberosity fractures. We hypothesized that greater tuberosity fractures displaced <5 mm may be managed nonoperatively and that greater tuberosity fractures displaced >5 mm require surgical fixation.
Methods
Search Strategy
We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist11 and registered it (CRD42014010691) with the PROSPERO international prospective register of systematic reviews. Literature searches using the PubMed/Medline database and the Cochrane Central Register of Clinical Trials were completed in August 2014. There were no date or year restrictions. Key words were used to capture all English- language studies with level I to IV evidence (Oxford Centre for Evidence-Based Medicine) and reported clinical or radiographic outcomes. Initial exclusion criteria were cadaveric, biomechanical, histologic, and kinematic results. An electronic search algorithm with key words and a series of NOT phrases was designed to match our exclusion criteria:
((((((((((((((((((((((((((((((((((((((((((((((((((greater[Title/Abstract]) AND tuberosity [Title/Abstract] OR tubercle [Title/Abstract]) AND fracture[Title/Abstract]) AND proximal[Title/Abstract] AND (English[lang]))) NOT intramedullary[Title] AND (English[lang]))) NOT nonunion[Title] AND (English[lang]))) NOT malunion[Title] AND (English[lang]))) NOT biomechanical[Title/Abstract] AND (English[lang]))) NOT cadaveric[Title/Abstract] AND (English[lang]))) NOT cadaver[Title/Abstract] AND (English[lang]))) NOT ((basic[Title/Abstract]) AND science[Title/Abstract] AND (English[lang])) AND (English[lang]))) NOT revision[Title] AND (English[lang]))) NOT pediatric[Title] AND (English[lang]))) NOT physeal[Title] AND (English[lang]))) NOT children[Title] AND (English[lang]))) NOT instability[Title] AND (English[lang]))) NOT imaging[Title])) NOT salter[Title])) NOT physis[Title])) NOT shaft[Title])) NOT distal[Title])) NOT clavicle[Title])) NOT scapula[Title])) NOT ((diaphysis[Title]) AND diaphyseal[Title]))) NOT infection[Title])) NOT laboratory[Title/Abstract])) NOT metastatic[Title/Abstract])) NOT (((((((malignancy[Title/Abstract]) OR malignant[Title/Abstract]) OR tumor[Title/Abstract]) OR oncologic[Title/Abstract]) OR cyst[Title/Abstract]) OR aneurysmal[Title/Abstract]) OR unicameral[Title/Abstract]).
Study Selection
We obtained 135 search results and reviewed them for further differentiation. All the references in these studies were cross-referenced for inclusion (if missed by the initial search), which added another 15 studies. Technical notes, letters to the editor, and level V evidence reviews were excluded. Double-counting of patients was avoided by comparing each study’s authors, data collection period, and ethnic population with those of the other studies. In cases of overlapping authorship, period, or place, only the study with the longer follow-up, more patients, or more comprehensive data was included. For studies separating outcomes by diagnosis, only outcomes of isolated greater tuberosity fractures were included. Data on 3- or 4-part proximal humerus fractures and isolated lesser tuberosity fractures were excluded. Studies that could not be deconstructed as such or that were devoted solely to one of our exclusion criteria were excluded. Minimum follow-up was 2 years. After all inclusion and exclusion criteria were accounted for, 13 studies with 429 patients (429 shoulders) were selected for inclusion (Figure, Table 1).2,5,12-22
Data Extraction
We extracted data from the 13 studies that met the eligibility criteria. Details of study design, sample size, and patient demographics, including age, sex, and hand dominance, were recorded, as were mechanism of injury and concomitant anterior shoulder instability. To capture the most patients, we noted radiographic fracture displacement categorically rather than continuously; patients were divided into 2 displacement groups (<5 mm, >5 mm). Most studies did not define degree of comminution or specific direction of displacement per fracture, so these variables were not included in the data analysis. Nonoperative management and operative management were studied. We abstracted surgical factors, such as approach, method, fixation type (screws or sutures), and technique (suture anchors or transosseous tunnels). Clinical outcomes included physical examination findings, functional assessment results (patient satisfaction; Constant and University of California Los Angeles [UCLA] shoulder scores), and the number of revisions. Radiologic outcomes, retrieved from radiographs or computed tomography scans, focused on loss of reduction (as determined by the respective authors), malunion, nonunion, and heterotopic ossification. Each study’s methodologic quality and bias were evaluated with the 15-item Modified Coleman Methodology Score (MCMS), which was described by Cowan and colleagues.23 The MCMS has been used to assess randomized and nonrandomized patient trials.24,25 Its scaled potential score ranges from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor).
Statistical Analysis
We report our data as weighted means (SDs). A mean was calculated for each study that reported a respective data point, and each mean was then weighed according to its study sample size. This calculation was performed by multiplying a study’s individual mean by the number of patients enrolled in that study and dividing the sum of these weighted data points by the number of eligible patients in all relevant studies. The result was that the nonweighted means from studies with smaller sample sizes did not carry as much weight as the nonweighted means from larger studies. We compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic). Regarding all patient, surgery, and outcomes data, unpaired Student t tests were used for continuous variables and 2-tailed Fisher exact tests for categorical variables with α = 0.05 (SPSS Version 18; IBM).
Results
Demographic information and treatment strategies are listed in Table 2. Fifty-eight percent of patients were male, 59.0% of dominant shoulders were affected, and 59.2% of fractures were displaced <5 mm. Concomitant shoulder instability was reported in 28.1% of patients. Mechanism of injury was not reported in all studies but most commonly (n = 75; 49.3%) involved a fall on an outstretched hand; 31 patients (20.4%) had a sports-related injury, and another 37 (24.3%) were injured in a motor vehicle collision. Of the 429 patients, 217 (50.6%) were treated nonoperatively, and 212 (49.4%) underwent surgery. Open, arthroscopic, and percutaneous approaches were reported. No studies presented outcomes of fragment excision.
Postoperative physical examination findings were underreported so that surgical groups could be compared. Of all the surgical studies, 4 reported postoperative forward elevation (mean, 160°; SD, 9.8°) and external rotation (mean, 46.4°; SD 26.3°).14,15,18,22 No malunions and only 1 nonunion were reported in all 13 studies. No deaths or other serious medical complications were reported. Patients with anterior instability more often underwent surgery than were treated nonoperatively (39.2% vs 12.0%; P < .01) and more often had fractures displaced >5 mm than <5 mm (44.3% vs 14.5%; P < .01).
Comparisons of treatment type are listed in Table 3. Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (P < .01) and better patient satisfaction (P < .01). Operative patients had a significantly higher rate of shoulder stiffness (P < .01). Eight operative patients (3.8%) and no nonoperative patients required reoperation during clinical follow-up (P < .01). All 12 reported cases of stiffness were in the operative group, and 3 required revision surgery. One patient required revision ORIF. There were 2 cases of postoperative superficial infection (0.9%) and 4 neurologic injuries (1.9%).
Comparisons of displacement amount are listed in Table 4. Compared with fractures displaced >5 mm, those displaced <5 mm had more radiographic losses of reduction (P < .01) but fewer instances of heterotopic ossification (P < .01). Fractures displaced >5 mm were significantly more likely than not to be managed with surgery (P < .01) and significantly more likely to develop stiffness after treatment (P = .01). One patient (0.4%) with a fracture displaced <5 mm eventually underwent surgery for stiffness, and 6 patients (3.6%) with fractures displaced >5 mm required reoperation (P = .02).
Comparisons of surgery type are listed in Table 5. All open procedures were performed with a deltoid-splitting approach. Screw fixation was used in 4 cases: 2 percutaneous5,21 and 2 open.2,5 The other open and arthroscopic studies described suture fixation, half with anchors (77/156 patients; 49.4%) and half with transosseous tunnels (79/156; 50.6%). There were no statistically significant differences between open/percutaneous and arthroscopic techniques in terms of stiffness, superficial infection, neurologic injury, or reoperation rate.
Fisher exact tests were used to perform isolated comparisons of screws and sutures as well as suture anchors and transosseous tunnels. Patients with screw fixation were significantly (P = .051) less likely to require reoperation (0/56; 0%) than patients with suture fixation (8/100; 8.0%). Screw fixation also led to significantly less stiffness (0% vs 12.0%; P < .01) but trended toward a higher rate of superficial infection (3.6% vs 0%; P = .13). There was no statistical difference in nerve injury rates between screws and sutures (1.8% vs 3.0%; P = 1.0). There were no significant differences in reoperations, stiffness, superficial infections, or nerve injuries between suture anchor and transosseous tunnel constructs.
For all 13 studies, mean (SD) MCMS was 41.1 (8.6).
Discussion
Five percent of all fractures involve the proximal humerus, and 20% of proximal humerus fractures are isolated greater tuberosity fractures.26,27 In his classic 1970 article, Neer6 formulated the 4-part proximal humerus fracture classification and defined greater tuberosity fracture “parts” using the same criteria as for other fracture “parts.” Neer6 recommended nonoperative management for isolated greater tuberosity fractures displaced <1 cm but did not present evidence corroborating his recommendation. More recent cutoffs for nonoperative management include 5 mm (general population) and 3 mm (athletes).7,17
In the present systematic review of greater tuberosity fractures, 3 separate comparisons were made: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).
Treatment Type. Only 4 studies reported data on nonoperative treatment outcomes.5,12,16,17 Of these 4 studies, 2 found successful outcomes for fractures displaced <5 mm.12,17 Platzer and colleagues17 found good or excellent results in 97% of 135 shoulders after 4 years. Good results were defined with shoulder scores of ≥80 (Constant), <8 (Vienna), and >28 (UCLA), and excellent results were defined with maximum scores on 2 of the 3 systems. Platzer and colleagues17 also found nonsignificantly worse shoulder scores with superior displacement of 3 mm to 5 mm and recommended surgery for overhead athletes in this group. Rath and colleagues12 described a successful 3-phase rehabilitation protocol of sling immobilization for 3 weeks, pendulum exercises for 3 weeks, and active exercises thereafter. By an average of 31 months, patient satisfaction scores improved to 9.5 from 4.2 (10-point scale), though the authors cautioned that pain and decreased motion lasted 8 months on average. Conservative treatment was far less successful in the 2 studies of fractures displaced >5 mm.5,16 Keene and colleagues16 reported unsatisfactory results in all 4 patients with fractures displaced >1.5 cm. In a study separate from their 2005 analysis,17 Platzer and colleagues5 in 2008 evaluated displaced fractures and found function and patient satisfaction were inferior after nonoperative treatment than after surgery. The studies by Keene and colleagues16 and Platzer and colleagues5 support the finding of an overall lower patient satisfaction rate in nonoperative patients.
Fracture Displacement Amount. Only 2 arthroscopic studies and no open studies addressed surgery for fractures displaced <5 mm. Fewer than 16% of these fractures were managed operatively, and <1% required reoperation. By contrast, almost all fractures displaced >5 mm were managed operatively, and 3.6% required reoperation. Radiographic loss of reduction was more common in fractures displaced <5 mm, primarily because they were managed without fixation. Radiographic loss of reduction was reported in only 9 operatively treated patients, none of whom was symptomatic enough to require another surgery.5 Reoperations were most commonly performed for stiffness, which itself was significantly more common in fractures displaced >5 mm. Bhatia and colleagues14 reported the highest reoperation rate (14.3%; 3/21), but they studied more complex, comminuted fractures of the greater tuberosity. Two of their 3 reoperations were biceps tenodeses for inflamed, stiff tenosynovitis, and the third patient had a foreign body giant cell reaction to suture material. Fewer than 1% of patients with operatively managed displaced fractures required revision ORIF, and <2% developed a superficial infection or postoperative nerve palsy.19,22 For displaced greater tuberosity fractures, surgery is highly successful overall, complication rates are very low, and 90% of patients report being satisfied.
Surgery Type. Patients were divided into 2 groups. In the nonarthroscopic group, open and percutaneous approaches were used. All studies that described a percutaneous approach used screw fixation5,21; in addition, 32 patients were treated with screws through an open approach.2,5 The other open and arthroscopic studies used suture fixation. Interestingly, no studies reported on clinical outcomes of fragment excision. There were no statistically significant differences in rates of reoperation, stiffness, infection, or neurologic injury between the arthroscopic and nonarthroscopic groups. Patient satisfaction scores were slightly higher in the nonarthroscopic group (91.0% vs 87.8%), but the difference was not statistically significant.
With surgical techniques isolated, there were no significant differences between suture anchors and transosseous tunnel constructs, but screws performed significantly better than suture techniques. Compared with suture fixation, screw fixation led to significantly fewer cases of stiffness and reoperation, which suggests surgeons need to give screws more consideration in the operative management of these fractures. However, the number of patients treated with screws was smaller than the number treated with suture fixation; it is possible the differences between these cohorts would be eliminated if there were more patients in the screw cohort. In addition, screw fixation was universally performed with an open or percutaneous approach and trended toward a higher infection rate. As screw and suture techniques have low rates of complications and reoperations, we recommend leaving fixation choice to the surgeon.
Anterior shoulder instability has been associated with greater tuberosity fractures.1,8,19 The supraspinatus, infraspinatus, and teres minor muscles all insert into the greater tuberosity and resist anterior translation of the proximal humerus. Loss of this dynamic muscle stabilization is amplified by tuberosity fracture displacement: Anterior shoulder instability was significantly more common in fractures displaced >5 mm (44.3%) vs <5 mm (14.5%). In turn, glenohumeral instability was more common in patients treated with surgery, specifically open surgery, because displaced fractures may not be as easily accessed with arthroscopic techniques. No studies reported concomitant labral repair or capsular plication techniques.
This systematic review was limited by the studies analyzed. All but 1 study5 had level IV evidence. Mean (SD) MCMS was 41.8 (8.6). Any MCMS score <54 indicates a poor methodology level, but this scoring system is designed for randomized controlled trials,23 and there were none in this study. Physical examination findings, such as range of motion, were underreported. In addition, radiographic parameters were not consistently described but rather were determined by the respective authors’ subjective interpretations of malunion, nonunion, and loss of reduction. Publication bias is present in that we excluded non- English language studies and medical conference abstracts and may have omitted potentially eligible studies not discoverable with our search methodology. Performance bias is a factor in any systematic review with multiple surgeons and wide variation in surgical technique.
Conclusion
Greater tuberosity fractures displaced <5 mm may be safely managed nonoperatively, as there are no reports of nonoperatively managed fractures that subsequently required surgery. Nonoperative treatment was initially associated with low patient satisfaction, but only because displaced fractures were conservatively managed in early studies.5,16 Fractures displaced >5 mm respond well to operative fixation with screws, suture anchors, or transosseous suture tunnels. Stiffness is the most common postoperative complication (<6%), followed by heterotopic ossification, transient neurapraxias, and superficial infection. There are no discernible differences in outcome between open and arthroscopic techniques, but screw fixation may lead to significantly fewer cases of stiffness and reoperation in comparison with suture constructs.
1. Verdano MA, Aliani D, Pellegrini A, Baudi P, Pedrazzi G, Ceccarelli F. Isolated fractures of the greater tuberosity in proximal humerus: does the direction of displacement influence functional outcome? An analysis of displacement in greater tuberosity fractures. Acta Biomed. 2013;84(3):219-228.
2. Yin B, Moen TC, Thompson SA, Bigliani LU, Ahmad CS, Levine WN. Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes. Orthopedics. 2012;35(6):e807-e814.
3. Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12(6):641-649.
4. Norouzi M, Naderi MN, Komasi MH, Sharifzadeh SR, Shahrezaei M, Eajazi A. Clinical results of using the proximal humeral internal locking system plate for internal fixation of displaced proximal humeral fractures. Am J Orthop. 2012;41(5):E64-E68.
5. Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma. 2008;65(4):843-848.
6. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
7. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Jt Dis. 1997;56(3):171-176.
8. McLaughlin HL. Dislocation of the shoulder with tuberosity fracture. Surg Clin North Am. 1963;43:1615-1620.
9. DeBottis D, Anavian J, Green A. Surgical management of isolated greater tuberosity fractures of the proximal humerus. Orthop Clin North Am. 2014;45(2):207-218.
10. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong). 2009;17(2):142-145.
11. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.
12. Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elbow Surg. 2013;22(10):e8-e11.
13. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am. 2007;89(8):1700-1709.
14. Bhatia DN, van Rooyen KS, Toit du DF, de Beer JF. Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results. Injury. 2006;37(10):946-952.
15. Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991;73(8):1213-1218.
16. Keene JS, Huizenga RE, Engber WD, Rogers SC. Proximal humeral fractures: a correlation of residual deformity with long-term function. Orthopedics. 1983;6(2):173-178.
17. Platzer P, Kutscha-Lissberg F, Lehr S, Vecsei V, Gaebler C. The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity. Injury. 2005;36(10):1185-1189.
18. Park SE, Ji JH, Shafi M, Jung JJ, Gil HJ, Lee HH. Arthroscopic management of occult greater tuberosity fracture of the shoulder. Eur J Orthop Surg Traumatol. 2014;24(4):475-482.
19. Dimakopoulos P, Panagopoulos A, Kasimatis G, Syggelos SA, Lambiris E. Anterior traumatic shoulder dislocation associated with displaced greater tuberosity fracture: the necessity of operative treatment. J Orthop Trauma. 2007;21(2):104-112.
20. Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy. 2000;16(7):695-700.
21. Chen CY, Chao EK, Tu YK, Ueng SW, Shih CH. Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma. 1998;45(6):1039-1045.
22. Ji JH, Shafi M, Song IS, Kim YY, McFarland EG, Moon CY. Arthroscopic fixation technique for comminuted, displaced greater tuberosity fracture. Arthroscopy. 2010;26(5):600-609.
23. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.
24. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. 2010;92(12):2220-2233.
25. Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation—a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791.
26. Chun JM, Groh GI, Rockwood CA. Two-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1994;3(5):273-287.
27. Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humeral: current concepts. Injury. 2008;39(3):284-298.
1. Verdano MA, Aliani D, Pellegrini A, Baudi P, Pedrazzi G, Ceccarelli F. Isolated fractures of the greater tuberosity in proximal humerus: does the direction of displacement influence functional outcome? An analysis of displacement in greater tuberosity fractures. Acta Biomed. 2013;84(3):219-228.
2. Yin B, Moen TC, Thompson SA, Bigliani LU, Ahmad CS, Levine WN. Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes. Orthopedics. 2012;35(6):e807-e814.
3. Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12(6):641-649.
4. Norouzi M, Naderi MN, Komasi MH, Sharifzadeh SR, Shahrezaei M, Eajazi A. Clinical results of using the proximal humeral internal locking system plate for internal fixation of displaced proximal humeral fractures. Am J Orthop. 2012;41(5):E64-E68.
5. Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma. 2008;65(4):843-848.
6. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
7. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI. A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Jt Dis. 1997;56(3):171-176.
8. McLaughlin HL. Dislocation of the shoulder with tuberosity fracture. Surg Clin North Am. 1963;43:1615-1620.
9. DeBottis D, Anavian J, Green A. Surgical management of isolated greater tuberosity fractures of the proximal humerus. Orthop Clin North Am. 2014;45(2):207-218.
10. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong). 2009;17(2):142-145.
11. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.
12. Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elbow Surg. 2013;22(10):e8-e11.
13. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am. 2007;89(8):1700-1709.
14. Bhatia DN, van Rooyen KS, Toit du DF, de Beer JF. Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results. Injury. 2006;37(10):946-952.
15. Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991;73(8):1213-1218.
16. Keene JS, Huizenga RE, Engber WD, Rogers SC. Proximal humeral fractures: a correlation of residual deformity with long-term function. Orthopedics. 1983;6(2):173-178.
17. Platzer P, Kutscha-Lissberg F, Lehr S, Vecsei V, Gaebler C. The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity. Injury. 2005;36(10):1185-1189.
18. Park SE, Ji JH, Shafi M, Jung JJ, Gil HJ, Lee HH. Arthroscopic management of occult greater tuberosity fracture of the shoulder. Eur J Orthop Surg Traumatol. 2014;24(4):475-482.
19. Dimakopoulos P, Panagopoulos A, Kasimatis G, Syggelos SA, Lambiris E. Anterior traumatic shoulder dislocation associated with displaced greater tuberosity fracture: the necessity of operative treatment. J Orthop Trauma. 2007;21(2):104-112.
20. Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy. 2000;16(7):695-700.
21. Chen CY, Chao EK, Tu YK, Ueng SW, Shih CH. Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma. 1998;45(6):1039-1045.
22. Ji JH, Shafi M, Song IS, Kim YY, McFarland EG, Moon CY. Arthroscopic fixation technique for comminuted, displaced greater tuberosity fracture. Arthroscopy. 2010;26(5):600-609.
23. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.
24. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. 2010;92(12):2220-2233.
25. Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation—a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791.
26. Chun JM, Groh GI, Rockwood CA. Two-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1994;3(5):273-287.
27. Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humeral: current concepts. Injury. 2008;39(3):284-298.
A Systematic Review of 21 Tibial Tubercle Osteotomy Studies and More Than 1000 Knees: Indications, Clinical Outcomes, Complications, and Reoperations
Take-Home Points
- TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
- Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
- TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
- Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
- While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.
Patellofemoral pain and patellofemoral instability are common orthopedic problems. Studies have found that 30% of patients 13 to 19 years old have patellofemoral pain and that 29 in 100,000 patients 10 to 17 years old have patellofemoral instability.1-3 The reported rate of recurrence after nonoperative management of patellofemoral instability is 33%.4 Tibial tubercle osteotomy (TTO), first described by Hauser5 in 1938, is an effective treatment option for many patellofemoral disorders.
TTO indications include patellofemoral maltracking or malalignment, patellar instability, patellofemoral arthritis, and focal patellofemoral chondral defects.6 With TTO, the goal is to move the tibial tubercle in a direction that will either improve patellar tracking or offload the medial or lateral patellar facet to improve pain and function.7,8 This action typically involves anterior, medial, lateral, or distal translation of the tibial tubercle, as posteriorization can lead to increased contact forces across the patellofemoral joint, resulting in accelerated patellofemoral wear and increased pain.9
We systematically reviewed the TTO literature to identify indications, clinical outcomes, complications, and reoperations. We hypothesized that the overall complication rate and the overall reoperation rate would both be <10%.
Clinical Evaluation of Patellofemoral Pathology
Patients with patellofemoral pain often report anterior knee pain, which typically begins gradually and is often activity related. Several symptoms may be present: pain with prolonged sitting with knees bent; pain on rising from a seated position; pain or crepitus with climbing stairs; and pain during repetitive activity such as running, squatting, or jumping. Location, duration, and onset of symptoms should be elicited. Patellofemoral instability can be described as dislocation events or subluxation events; number of events, mechanisms of injury, and resulting need for reduction should be documented. As age, sex, body mass index, and physical fitness are relevant to risk of recurrence, the physician should ask about general ligamentous laxity, other joint dislocations, and prior surgical intervention. Swelling or mechanical symptoms may indicate patellofemoral joint pathology.6,10
Physical examination of patients with patellofemoral pathology begins with assessment for overall limb alignment (including resting position of patella and corresponding quadriceps angle [Q-angle]), generalized ligamentous laxity (including hypermobile joints, evaluated with Brighton criteria), overall peri-knee muscle tone and strength, effusion, and gait pattern. Knee and hip range of motion should be documented. Apprehension (Figure 1) and lack of a firm endpoint on placement of a lateralizing moment on the patella suggest prior dislocation or subluxation. Patella and surrounding anatomy must be palpated for location and severity of tenderness. Finally, patellar tilt, height, mobility, and dynamic tracking, including J-sign, are pertinent to evaluation. The J-sign for patellar tracking is positive when the patella deviates laterally as the knee moves from flexion into extension. Examination of the asymptomatic contralateral side is essential for comparison. Plain radiographs are important first-line imaging. Computed tomography or magnetic resonance imaging can be used to measure tibial tubercle-trochlear groove (TT-TG) distance. TT-TG distance of >15 mm is abnormal, and >20 mm indicates TTO is required. Advanced imaging is additionally valuable in assessing for chondral injury or trochlear dysplasia.6,10
Common TTO Procedures
TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects. Essentially, the patella is translated to offload the affected areas. Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization. Lateralization or anterolateralization may be pertinent to revision if an osteotomy direction results in overcorrection of tuberosity position. Anteriorization (Figures 2A-2C) does not have a role in patellofemoral instability, but can unload areas of excessive patellar chondral force concentration at the central or proximal patella by increasing the angle between the patellar and quadriceps tendons and thereby decreasing the joint reaction forces. Straight medialization (Figures 3A, 3B) offloads lateral patellar chondral injury and may decrease lateral instability. Distalization (Figures 4A-4C) can correct for patella alta in the setting of patellar instability and allows earlier engagement of the patella in the trochlea to increase osseous restraint to lateral translation.6
Anteromedialization (Figure 5) is indicated in patients with a normal proximal and medial patellar chondral surface and a laterally positioned patella leading to alteration of the contact area in the trochlear groove and resulting pain, lateral patellar or trochlear chondral disease, or instability. Osteotomy angle can provide varied medialization through consistent slope and anteriorization. For example, a 60° slope osteotomy provides 9 mm of medialization with 15 mm of anteriorization.6 The procedure, similar to the additional TTO operations, begins with a lateral parapatellar incision that is extended distal to the tibial tubercle and anterior over the crest. The soft tissues around the tubercle are released to allow mobilization. Variable osteotomy jigs allow for different slope cuts for more medialization or anteriorization, based on preoperative findings. The osteotomy cuts are started with a thin oscillating blade (Figure 6) and finished with an osteotome. The tubercle fragment (Figure 7) is shifted and provisionally fixed with a Kirschner wire before being drilled and fixated with two 4.5-mm countersunk cortical screws (Figures 8, 9A-9B). Locally harvested corticocancellous bone can help anteriorize the tubercle block. Osteotomy specifics allow for corresponding anatomical translations of the TTO to address the preoperative pathology.
Methods
Search Strategy and Data Collection
We searched the PubMed (Medline) database for all English-language TTO studies published between database inception and April 9, 2015. After PROSPERO registration, and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we used the algorithm (“tibial” AND “tubercle” AND “osteotomy”) NOT (“total” AND “knee” AND “arthroplasty”) to search the literature. Inclusion criteria included level I-IV studies on TTO indications, operative findings, and outcomes. Exclusion criteria were non-English studies, unpublished studies, level V evidence, letters to the editor, editorials, review articles, basic science articles, technique articles, revision procedures, articles without clinical outcomes, and conference proceeding abstracts. Studies that reported on duplicate populations were included only with the most recent available clinical outcomes. All abstracts were reviewed in duplicate by Dr. Levy and Dr. Rao and assessed with respect to the criteria outlined. Then the same authors performed full-text reviews of eligible studies before including these studies in the systematic review. They also manually checked the references in study articles to identify additional studies for possible inclusion in the review. A standardized form created by the authors at the start of the review was used to extract data (Table 1).
Assessment of Study Quality
The quality of each TTO study in the review was assessed with a modified Coleman methodology score (MCMS), which ranges from 0 to 100. A study with an MCMS of <55 points is considered a poor-quality study.11
Data Synthesis and Statistical Analysis
Given that most of the included studies were level IV, a formal meta-analysis was not indicated. In this article, we report categorical data as frequencies with percentages and preoperative and postoperative continuous data as means (SDs), with weighted means based on number of patients in each study, where applicable. We used 2-tailed t tests for comparisons made with the free Meta-Analysis Calculator and Grapher (http://www.healthstrategy.com/meta/meta.pl ). Statistical significance was set at P < .05.
Results
Search Results and Included Studies
Twenty-one studies (976 patients, 1055 knees) were included in the analysis (Figure 10; Table 2).12-32 These studies were published between 1986 and 2013. There were 18 level IV studies (85.7%), 3 level III studies (14%), and no level I or II studies. Better quality studies had a mean (SD) MCMS of 19.8 (8.2), well under the 55-point cutoff. In the 16 studies that reported sex, women accounted for 69% of the population. Weighted mean (SD) age was 27.68 (10.45) years (range, 12-77 years) (18 studies reporting).
Only 1 study provided preoperative body mass index (27 kg/m2). There were 55.35% of patients who had prior surgery on the affected knee (6 studies reporting).
Preoperative Data
Preoperative pathologic, radiographic, and clinical scoring data were scarcely reported and nonuniform (Table 2). The most common pathology treated with TTO was isolated patellofemoral instability (746/1055 patients, 70.7%). The other pathologies addressed were isolated patellofemoral osteoarthritis/chondromalacia patellae (143, 13.6%), patellofemoral instability with patella alta (61, 5.8%), patellofemoral instability with patellofemoral osteoarthritis (45, 4.3%), isolated patella baja (41, 3.9%), isolated patella alta (19, 1.8%), and patellofemoral osteoarthritis with patella baja (2, 0.2%). Five hundred fifty-five patients (53%) had a preoperative complaint that included knee pain, and 809 (77%) reported preoperative patellar laxity or instability events. The imaging data reported were Q-angle, Insall-Salvati ratio, Caton-Deschamps index, Blackburne-Peel ratio, Outerbridge osteoarthritis grade, and TT-TG distance. Preoperative clinical scoring data most prominently included a visual analog scale (VAS) score of 70.50 (4 studies reporting), a Lysholm score of 59.19 (5 studies), and a Kujala score of 41.16 (4 studies). Shelbourne-Trumper and Cox-Insall scores were reported in 1 and 2 studies, respectively.
Operative Characteristics
Of the 21 studies, 12 reported only on patients who had TTO performed in isolation; in the other 9 studies, cohorts included patients who underwent concurrent procedures. In the 17 studies (856 patients) that listed numbers of patients who underwent specific concomitant procedures, 715 patients (83.5%) underwent an isolated TTO procedure, and the other 141 (16.5%) underwent either concomitant lateral femoral trochleoplasty, arthroscopic drilling of chondral lesions, patellar shaving chondroplasty, partial meniscectomy or concomitant meniscal repair, intra-articular loose body removal, and/or lateral release with or without medial plication.
Twenty studies reported specifics on the intraoperative direction of the tibial bone block osteotomy (Table 3). In most cases (50.8%), anteromedial translation (anteromedialization) was performed; anteriorization was performed in 18.7% of cases, medialization in 9.6%, medial and distal translation in 7.2%, a “triple” (anteriorization, medialization, proximalization) in 6%, isolated distalization in 2.8%, and proximalization in 1.6%. The remaining 2.8% of procedure specifics were not identified.
Postoperative Data
Table 4 lists the overall cohort’s postoperative radiographic, clinical outcome scoring, and complications data. Fifteen studies reported follow-up of >2 years. As with the preoperative data, radiographic and clinical scoring data were relatively nonuniform; some numeric data, however, should be highlighted. Statistical analysis allowed for comparison of preoperative-postoperative VAS, Lysholm, and Kujala scores, each of which was significantly higher after surgery (P < .001). Seven studies reported an overall clinical outcome rating, with the cumulative majority of patients reporting good (37.9%) or excellent (39.2%) results.
There was a cumulative total of 79 complications (8% of cohort): 17 recurrent patellar dislocations (1.9%), 4 recurrent patellar subluxations (0.4%), 10 wound complications (1.0%), 2 intraoperative complications (0.2%), 14 tibial tubercle fractures (1.3%), 19 proximal tibia fractures (1.8%), 4 cases of anterior knee pain (0.4%), 4 cases of neuropraxia (0.4%), and 5 infections (0.5%). Of note, 219 knees (21%) required reoperation, but 170 (16.3%) of these were for painful hardware removal. Sixteen knees (1.5%) required revision TTO, 1 (0.1%) required subsequent high tibial osteotomy, 2 (0.2%) underwent patellofemoral arthroplasty for advanced arthritic changes, and 5 (0.5%) underwent total knee arthroplasty for advanced arthritic changes.
Studies With TTO Performed in Isolation
Twelve studies reported outcomes of isolated TTO procedures. In the 638 patients who underwent isolated TTO, the pathologies addressed were instability/laxity (429 patients, 67%), patellofemoral osteoarthritis (74, 12%), patella alta with instability (61, 10%), patellofemoral osteoarthritis with instability (31, 5%), patella baja (24, 4%), and patella alta (19, 3%). Pain was a preoperative issue in 289 (45%) of these patients and instability in 472 (74%).
Only 2.8% of patients experienced postoperative patellar dislocation events. Of the 12 studies, 2 reported VAS scores (34-point weighted mean improvement, 65 points before surgery to 31 after surgery), 3 reported Lysholm scores (30-point improvement, from 60 to 90), and 2 reported Kujala scores (21-point improvement, from 46 to 67).
Complication rates for this isolated-TTO pooled cohort of patients were 1.2% for revision TTOs, 0.5% for wound complications, 0.8% for tibial tubercle fractures, and 1.9% for proximal tibia fractures. In total, 16% of patients required hardware removal after surgery.
Discussion
This study found that TTO improved patient pain and clinical outcome scores despite having a high (16%) rate of reoperation for painful hardware in patients with preoperative pain or instability, or with patellofemoral osteoarthritis or aberrant patellar anatomy. This reoperation rate and the overall complication rate both exceeded our hypothesized 10% cumulative rate. However, <1% of patients required conversion to a definitive end-stage surgery (patellofemoral arthroplasty or total knee arthroplasty) by final follow-up, and the rates of comorbidities (anterior knee pain, wound infection, recurrent patellar subluxation/dislocation, tibial fracture) were relatively low.
Patellofemoral disorders are common in the general population and a frequent primary complaint on presentation to orthopedic offices. Having a thorough understanding of knee joint biomechanics is imperative when trying to determine whether surgery is appropriate for these complaints and how to proceed. Extensor mechanism abnormalities, including high lateral force vectors (or larger TT-TG distances) and excessive patellar tilt, can affect alignment and increase the risk for patellofemoral dislocations, patellofemoral anterior- based knee pains, and chondral lesions. Patella alta, an elevated patella, risks increased contact stresses between the patella and the trochlear groove33 and decreases the osseous constraints that inhibit dislocation of the patella with physiologic flexion of the joint.34 With TTO, the change in tuberosity position can alter angles in the extensor mechanism and thereby decrease joint reaction forces and patellofemoral contact area forces.35,36
Although its use began as an option for combating patellar instability events in patients with predisposed patellofemoral kinematics,5 TTO has evolved in its therapeutic uses to include offloading patellar and trochlear focal chondral lesions and slowing progression of patellofemoral arthritis. Multiple iterations and modifications of the procedure have involved distal and medial transfer of the tibial tuberosity, medialization alone, concurrent anterior and medial elevation of the tuberosity, and proximal or distal transfers, depending on the pathology being corrected. Although TTO is highly versatile in treating multiple patellofemoral joint pathologies, this study found that its primary indication continues to be patellar instability, with anteromedialization as the most common direction of tubercle transfer in support of the medial structures providing the medial force vector that keeps the patella in place. These medial structures include the medial patellofemoral ligament, the vastus medialis obliquus, the medial patellotibial ligament, and the medial retinaculum.
Also notable was the relatively high rate of reoperation after TTO. However, >75% of reoperations were performed to remove painful hardware, and the need for reoperation seemed to have no effect on the statistically significant overall preoperative-to-postoperative improvement in VAS, Lysholm, and Kujala scores. Rates of definitive surgery for end-stage patellofemoral changes, including patellofemoral arthroplasty and total knee arthroplasty, were quite low at the weighted mean follow-up of several years after surgery, suggesting a role for TTO in avoiding arthroplasty. Although the infection rate was <1%, the rate of tibial tubercle or proximal tibia fractures was a cumulative 3.1%. Patients should be counseled on this complication risk, as treatment can require cast immobilization and weight-bearing limitations.24
The 69% proportion of women in the overall cohort and the mean (SD) age of 27.68 (10.45) years highlight the primary patient population that undergoes TTO. Compared with men, young women are more likely to have aberrant patellofemoral biomechanics, owing to their native anatomy, including their relatively larger Q-angle and TT-TG distance and thus increased lateral translational force vectors on the patella.37 In addition, more than half of patients who are having TTO underwent previous surgery on the affected knee—an indication that TTO is still not universally considered first-line in addressing patellofemoral pathology.
Limitations of the Analysis
The limitations of this analysis derive from the limitations of the included studies, which were mostly retrospective case series with relatively short follow-up. The low MCMS (<55) of all 21 studies highlights their low quality as well. These studies showed considerable heterogeneity in their reporting of specific preoperative, intraoperative, and postoperative radiographic, physical examination, and clinical outcome scores, which may be indicative of the relatively low rate of use of TTO, a procedure originally described decades ago. These studies also showed ample heterogeneity in the specific radiographic parameters or outcome scales they used to present their data. We were therefore limited in our ability to cohesively summarize and provide cumulative data points from the patients as a unified cohort. There was substantial variety in the procedures performed, surgical techniques used, concomitant pathologies addressed at time of surgery, and diagnoses treated—indicating a performance bias. This additionally precluded any significant meta-analysis within the patient cohort. A higher quality study, a randomized controlled trial, is needed to answer more definitively and completely the questions we left unanswered, including the effect on radiographic parameters, additional clinical outcomes, and patient satisfaction.
Conclusion
TTO is most commonly performed for isolated patellar instability in the presence of knee pain. Other pathologies addressed are patellofemoral osteoarthritis, and patella alta and patella baja with and without associated knee pain. TTO significantly improves knee pain and clinical outcome scores, though 21% of patients (>1 in 5) require reoperation for hardware removal. Young women with prior surgery on the affected knee are the primary patient population.
1. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7- year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64(4):393-400.
2. Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br. 1984;66(5):685-693.
3. Mehta VM, Inoue M, Nomura E, Fithian DC. An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc. 2007;15(2):78-81.
4. Erickson BJ, Mascarenhas R, Sayegh ET, et al. Does operative treatment of first-time patellar dislocations lead to increased patellofemoral stability? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31(6):1207-1215.
5. Hauser E. Total tendon transplant for slipping patella. Surg Gynecol Obstet. 1938;66:199-214.
6. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
7. Hall MJ, Mandalia VI. Tibial tubercle osteotomy for patello-femoral joint disorders. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):855-861.
8. Grawe B, Stein BS. Tibial tubercle osteotomy: indication and techniques. J Knee Surg. 2015;28(4):279-284.
9. Fulkerson JP. Disorders of the Patellofemoral Joint. 4th ed. Baltimore, MD: Williams & Wilkins; 1997.
10. Koh JL, Stewart C. Patellar instability. Clin Sports Med. 2014;33(3):461-476.
11. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. 2000;10(1):2-11.
12. Al-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Rel Res. 2002;(396):152-162.
13. Atkinson HD, Bailey CA, Anand S, Johal P, Oakeshott RD. Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees. Arch Orthop Trauma Surg. 2012;132(4):437-445.
14. Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop. 2010;34(2):305-309.
15. Dantas P, Nunes C, Moreira J, Amaral LB. Antero-medialisation of the tibial tubercle for patellar instability. Int Orthop. 2005;29(6):390-391.
16. Drexler M, Dwyer T, Marmor M, Sternheim A, Cameron HU, Cameron JC. The treatment of acquired patella baja with proximalize the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc. 2013;21(11):2578-2583.
17. Eager MR, Bader DA, Kelly JD 4th, Moyer RA. Delayed fracture of the tibia following anteromedialization osteotomy of the tibial tubercle: a report of 5 cases. Am J Sports Med. 2004;32(4):1041-1048.
18. Ebinger TP, Boezaart A, Albright JP. Modifications of the Fulkerson osteotomy: a pilot study assessment of a novel technique of dynamic intraoperative determination of the adequacy of tubercle transfer. Iowa Orthop J. 2007;27:61-64.
19. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;18(5):490-498.
20. Heatley FW, Allen PR, Patrick JH. Tibial tubercle advancement for anterior knee pain: a temporary or permanent solution. Clin Orthop Relat Res. 1986;(208):216-225.
21. Hirsh DM, Reddy DK. Experience with Maquet anterior tibial tubercle advancement for patellofemoral arthralgia. Clin Orthop Relat Res. 1980;(148):136-139.
22. Jack CM, Rajaratnam SS, Khan HO, Keast-Butler O, Butler-Manuel PA, Heatley FW. The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: a five-year prospective study. Bone Joint Res. 2012;1(8):167-173.
23. Koëter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar maltracking: results at two years. J Bone Joint Surg Br. 2007;89(2):180-185.
24. Luhmann SJ, Fuhrhop S, O’Donnell JC, Gordon JE. Tibial fractures after tibial tubercle osteotomies for patellar instability: a comparison of three osteotomy configurations. J Child Orthop. 2011;5(1):19-26.
25. Naranja RJ Jr, Reilly PJ, Kuhlman JR, Haut E, Torg JS. Long-term evaluation of the Elmslie-Trillat-Maquet procedure for patellofemoral dysfunction. Am J Sports Med. 1996;24(6):779-784.
26. Naveed MA, Ackroyd CE, Porteous AJ. Long-term (ten- to 15-year) outcome of arthroscopically assisted Elmslie-Trillat tibial tubercle osteotomy. Bone Joint J. 2013;95(4):478-485.
27. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009;37(7):1288-1300.
28. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP. Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am J Sports Med. 1997;25(4):533-537.
29. Shen HC, Chao KH, Huang GS, Pan RY, Lee CH. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med. 2007;35(12):2101-2108.
30. Stetson WB, Friedman MJ, Fulkerson JP, Cheng M, Buuck D. Fracture of the proximal tibia with immediate weightbearing after a Fulkerson osteotomy. Am J Sports Med. 1997;25(4):570-574.
31. Valenzuela L, Nemtala F, Orrego M, et al. Treatment of patellofemoral chondropathy with the Bandi tibial tubercle osteotomy: more than 10 years follow-up. Knee. 2011;18(2):94-97.
32. Wang CJ, Wong T, Ko JY, Siu KK. Triple positioning of tibial tubercle osteotomy for patellofemoral disorders. Knee. 2014;21(1):133-137.
33. Luyckx T, Didden K, Vandenneucker H, Labey L, Innocenti B, Bellemans J. Is there a biomechanical explanation for anterior knee pain in patients with patella alta? Influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg Br. 2009;91(3):344-350.
34. Mayer C, Magnussen RA, Servien E, et al. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Am J Sports Med. 2012;40(2):346-351.
35. Maquet P. Advancement of the tibial tuberosity. Clin Orthop Relat Res. 1976;(115):225-230.
36. Lewallen DG, Riegger CL, Myers ER, Hayes WC. Effects of retinacular release and tibial tubercle elevation in patellofemoral degenerative joint disease. J Orthop Res. 1990;8(6):856-862.
37. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence, I: measurements of incongruence. Clin Orthop Relat Res. 1983;(176):217-224.
Take-Home Points
- TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
- Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
- TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
- Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
- While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.
Patellofemoral pain and patellofemoral instability are common orthopedic problems. Studies have found that 30% of patients 13 to 19 years old have patellofemoral pain and that 29 in 100,000 patients 10 to 17 years old have patellofemoral instability.1-3 The reported rate of recurrence after nonoperative management of patellofemoral instability is 33%.4 Tibial tubercle osteotomy (TTO), first described by Hauser5 in 1938, is an effective treatment option for many patellofemoral disorders.
TTO indications include patellofemoral maltracking or malalignment, patellar instability, patellofemoral arthritis, and focal patellofemoral chondral defects.6 With TTO, the goal is to move the tibial tubercle in a direction that will either improve patellar tracking or offload the medial or lateral patellar facet to improve pain and function.7,8 This action typically involves anterior, medial, lateral, or distal translation of the tibial tubercle, as posteriorization can lead to increased contact forces across the patellofemoral joint, resulting in accelerated patellofemoral wear and increased pain.9
We systematically reviewed the TTO literature to identify indications, clinical outcomes, complications, and reoperations. We hypothesized that the overall complication rate and the overall reoperation rate would both be <10%.
Clinical Evaluation of Patellofemoral Pathology
Patients with patellofemoral pain often report anterior knee pain, which typically begins gradually and is often activity related. Several symptoms may be present: pain with prolonged sitting with knees bent; pain on rising from a seated position; pain or crepitus with climbing stairs; and pain during repetitive activity such as running, squatting, or jumping. Location, duration, and onset of symptoms should be elicited. Patellofemoral instability can be described as dislocation events or subluxation events; number of events, mechanisms of injury, and resulting need for reduction should be documented. As age, sex, body mass index, and physical fitness are relevant to risk of recurrence, the physician should ask about general ligamentous laxity, other joint dislocations, and prior surgical intervention. Swelling or mechanical symptoms may indicate patellofemoral joint pathology.6,10
Physical examination of patients with patellofemoral pathology begins with assessment for overall limb alignment (including resting position of patella and corresponding quadriceps angle [Q-angle]), generalized ligamentous laxity (including hypermobile joints, evaluated with Brighton criteria), overall peri-knee muscle tone and strength, effusion, and gait pattern. Knee and hip range of motion should be documented. Apprehension (Figure 1) and lack of a firm endpoint on placement of a lateralizing moment on the patella suggest prior dislocation or subluxation. Patella and surrounding anatomy must be palpated for location and severity of tenderness. Finally, patellar tilt, height, mobility, and dynamic tracking, including J-sign, are pertinent to evaluation. The J-sign for patellar tracking is positive when the patella deviates laterally as the knee moves from flexion into extension. Examination of the asymptomatic contralateral side is essential for comparison. Plain radiographs are important first-line imaging. Computed tomography or magnetic resonance imaging can be used to measure tibial tubercle-trochlear groove (TT-TG) distance. TT-TG distance of >15 mm is abnormal, and >20 mm indicates TTO is required. Advanced imaging is additionally valuable in assessing for chondral injury or trochlear dysplasia.6,10
Common TTO Procedures
TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects. Essentially, the patella is translated to offload the affected areas. Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization. Lateralization or anterolateralization may be pertinent to revision if an osteotomy direction results in overcorrection of tuberosity position. Anteriorization (Figures 2A-2C) does not have a role in patellofemoral instability, but can unload areas of excessive patellar chondral force concentration at the central or proximal patella by increasing the angle between the patellar and quadriceps tendons and thereby decreasing the joint reaction forces. Straight medialization (Figures 3A, 3B) offloads lateral patellar chondral injury and may decrease lateral instability. Distalization (Figures 4A-4C) can correct for patella alta in the setting of patellar instability and allows earlier engagement of the patella in the trochlea to increase osseous restraint to lateral translation.6
Anteromedialization (Figure 5) is indicated in patients with a normal proximal and medial patellar chondral surface and a laterally positioned patella leading to alteration of the contact area in the trochlear groove and resulting pain, lateral patellar or trochlear chondral disease, or instability. Osteotomy angle can provide varied medialization through consistent slope and anteriorization. For example, a 60° slope osteotomy provides 9 mm of medialization with 15 mm of anteriorization.6 The procedure, similar to the additional TTO operations, begins with a lateral parapatellar incision that is extended distal to the tibial tubercle and anterior over the crest. The soft tissues around the tubercle are released to allow mobilization. Variable osteotomy jigs allow for different slope cuts for more medialization or anteriorization, based on preoperative findings. The osteotomy cuts are started with a thin oscillating blade (Figure 6) and finished with an osteotome. The tubercle fragment (Figure 7) is shifted and provisionally fixed with a Kirschner wire before being drilled and fixated with two 4.5-mm countersunk cortical screws (Figures 8, 9A-9B). Locally harvested corticocancellous bone can help anteriorize the tubercle block. Osteotomy specifics allow for corresponding anatomical translations of the TTO to address the preoperative pathology.
Methods
Search Strategy and Data Collection
We searched the PubMed (Medline) database for all English-language TTO studies published between database inception and April 9, 2015. After PROSPERO registration, and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we used the algorithm (“tibial” AND “tubercle” AND “osteotomy”) NOT (“total” AND “knee” AND “arthroplasty”) to search the literature. Inclusion criteria included level I-IV studies on TTO indications, operative findings, and outcomes. Exclusion criteria were non-English studies, unpublished studies, level V evidence, letters to the editor, editorials, review articles, basic science articles, technique articles, revision procedures, articles without clinical outcomes, and conference proceeding abstracts. Studies that reported on duplicate populations were included only with the most recent available clinical outcomes. All abstracts were reviewed in duplicate by Dr. Levy and Dr. Rao and assessed with respect to the criteria outlined. Then the same authors performed full-text reviews of eligible studies before including these studies in the systematic review. They also manually checked the references in study articles to identify additional studies for possible inclusion in the review. A standardized form created by the authors at the start of the review was used to extract data (Table 1).
Assessment of Study Quality
The quality of each TTO study in the review was assessed with a modified Coleman methodology score (MCMS), which ranges from 0 to 100. A study with an MCMS of <55 points is considered a poor-quality study.11
Data Synthesis and Statistical Analysis
Given that most of the included studies were level IV, a formal meta-analysis was not indicated. In this article, we report categorical data as frequencies with percentages and preoperative and postoperative continuous data as means (SDs), with weighted means based on number of patients in each study, where applicable. We used 2-tailed t tests for comparisons made with the free Meta-Analysis Calculator and Grapher (http://www.healthstrategy.com/meta/meta.pl ). Statistical significance was set at P < .05.
Results
Search Results and Included Studies
Twenty-one studies (976 patients, 1055 knees) were included in the analysis (Figure 10; Table 2).12-32 These studies were published between 1986 and 2013. There were 18 level IV studies (85.7%), 3 level III studies (14%), and no level I or II studies. Better quality studies had a mean (SD) MCMS of 19.8 (8.2), well under the 55-point cutoff. In the 16 studies that reported sex, women accounted for 69% of the population. Weighted mean (SD) age was 27.68 (10.45) years (range, 12-77 years) (18 studies reporting).
Only 1 study provided preoperative body mass index (27 kg/m2). There were 55.35% of patients who had prior surgery on the affected knee (6 studies reporting).
Preoperative Data
Preoperative pathologic, radiographic, and clinical scoring data were scarcely reported and nonuniform (Table 2). The most common pathology treated with TTO was isolated patellofemoral instability (746/1055 patients, 70.7%). The other pathologies addressed were isolated patellofemoral osteoarthritis/chondromalacia patellae (143, 13.6%), patellofemoral instability with patella alta (61, 5.8%), patellofemoral instability with patellofemoral osteoarthritis (45, 4.3%), isolated patella baja (41, 3.9%), isolated patella alta (19, 1.8%), and patellofemoral osteoarthritis with patella baja (2, 0.2%). Five hundred fifty-five patients (53%) had a preoperative complaint that included knee pain, and 809 (77%) reported preoperative patellar laxity or instability events. The imaging data reported were Q-angle, Insall-Salvati ratio, Caton-Deschamps index, Blackburne-Peel ratio, Outerbridge osteoarthritis grade, and TT-TG distance. Preoperative clinical scoring data most prominently included a visual analog scale (VAS) score of 70.50 (4 studies reporting), a Lysholm score of 59.19 (5 studies), and a Kujala score of 41.16 (4 studies). Shelbourne-Trumper and Cox-Insall scores were reported in 1 and 2 studies, respectively.
Operative Characteristics
Of the 21 studies, 12 reported only on patients who had TTO performed in isolation; in the other 9 studies, cohorts included patients who underwent concurrent procedures. In the 17 studies (856 patients) that listed numbers of patients who underwent specific concomitant procedures, 715 patients (83.5%) underwent an isolated TTO procedure, and the other 141 (16.5%) underwent either concomitant lateral femoral trochleoplasty, arthroscopic drilling of chondral lesions, patellar shaving chondroplasty, partial meniscectomy or concomitant meniscal repair, intra-articular loose body removal, and/or lateral release with or without medial plication.
Twenty studies reported specifics on the intraoperative direction of the tibial bone block osteotomy (Table 3). In most cases (50.8%), anteromedial translation (anteromedialization) was performed; anteriorization was performed in 18.7% of cases, medialization in 9.6%, medial and distal translation in 7.2%, a “triple” (anteriorization, medialization, proximalization) in 6%, isolated distalization in 2.8%, and proximalization in 1.6%. The remaining 2.8% of procedure specifics were not identified.
Postoperative Data
Table 4 lists the overall cohort’s postoperative radiographic, clinical outcome scoring, and complications data. Fifteen studies reported follow-up of >2 years. As with the preoperative data, radiographic and clinical scoring data were relatively nonuniform; some numeric data, however, should be highlighted. Statistical analysis allowed for comparison of preoperative-postoperative VAS, Lysholm, and Kujala scores, each of which was significantly higher after surgery (P < .001). Seven studies reported an overall clinical outcome rating, with the cumulative majority of patients reporting good (37.9%) or excellent (39.2%) results.
There was a cumulative total of 79 complications (8% of cohort): 17 recurrent patellar dislocations (1.9%), 4 recurrent patellar subluxations (0.4%), 10 wound complications (1.0%), 2 intraoperative complications (0.2%), 14 tibial tubercle fractures (1.3%), 19 proximal tibia fractures (1.8%), 4 cases of anterior knee pain (0.4%), 4 cases of neuropraxia (0.4%), and 5 infections (0.5%). Of note, 219 knees (21%) required reoperation, but 170 (16.3%) of these were for painful hardware removal. Sixteen knees (1.5%) required revision TTO, 1 (0.1%) required subsequent high tibial osteotomy, 2 (0.2%) underwent patellofemoral arthroplasty for advanced arthritic changes, and 5 (0.5%) underwent total knee arthroplasty for advanced arthritic changes.
Studies With TTO Performed in Isolation
Twelve studies reported outcomes of isolated TTO procedures. In the 638 patients who underwent isolated TTO, the pathologies addressed were instability/laxity (429 patients, 67%), patellofemoral osteoarthritis (74, 12%), patella alta with instability (61, 10%), patellofemoral osteoarthritis with instability (31, 5%), patella baja (24, 4%), and patella alta (19, 3%). Pain was a preoperative issue in 289 (45%) of these patients and instability in 472 (74%).
Only 2.8% of patients experienced postoperative patellar dislocation events. Of the 12 studies, 2 reported VAS scores (34-point weighted mean improvement, 65 points before surgery to 31 after surgery), 3 reported Lysholm scores (30-point improvement, from 60 to 90), and 2 reported Kujala scores (21-point improvement, from 46 to 67).
Complication rates for this isolated-TTO pooled cohort of patients were 1.2% for revision TTOs, 0.5% for wound complications, 0.8% for tibial tubercle fractures, and 1.9% for proximal tibia fractures. In total, 16% of patients required hardware removal after surgery.
Discussion
This study found that TTO improved patient pain and clinical outcome scores despite having a high (16%) rate of reoperation for painful hardware in patients with preoperative pain or instability, or with patellofemoral osteoarthritis or aberrant patellar anatomy. This reoperation rate and the overall complication rate both exceeded our hypothesized 10% cumulative rate. However, <1% of patients required conversion to a definitive end-stage surgery (patellofemoral arthroplasty or total knee arthroplasty) by final follow-up, and the rates of comorbidities (anterior knee pain, wound infection, recurrent patellar subluxation/dislocation, tibial fracture) were relatively low.
Patellofemoral disorders are common in the general population and a frequent primary complaint on presentation to orthopedic offices. Having a thorough understanding of knee joint biomechanics is imperative when trying to determine whether surgery is appropriate for these complaints and how to proceed. Extensor mechanism abnormalities, including high lateral force vectors (or larger TT-TG distances) and excessive patellar tilt, can affect alignment and increase the risk for patellofemoral dislocations, patellofemoral anterior- based knee pains, and chondral lesions. Patella alta, an elevated patella, risks increased contact stresses between the patella and the trochlear groove33 and decreases the osseous constraints that inhibit dislocation of the patella with physiologic flexion of the joint.34 With TTO, the change in tuberosity position can alter angles in the extensor mechanism and thereby decrease joint reaction forces and patellofemoral contact area forces.35,36
Although its use began as an option for combating patellar instability events in patients with predisposed patellofemoral kinematics,5 TTO has evolved in its therapeutic uses to include offloading patellar and trochlear focal chondral lesions and slowing progression of patellofemoral arthritis. Multiple iterations and modifications of the procedure have involved distal and medial transfer of the tibial tuberosity, medialization alone, concurrent anterior and medial elevation of the tuberosity, and proximal or distal transfers, depending on the pathology being corrected. Although TTO is highly versatile in treating multiple patellofemoral joint pathologies, this study found that its primary indication continues to be patellar instability, with anteromedialization as the most common direction of tubercle transfer in support of the medial structures providing the medial force vector that keeps the patella in place. These medial structures include the medial patellofemoral ligament, the vastus medialis obliquus, the medial patellotibial ligament, and the medial retinaculum.
Also notable was the relatively high rate of reoperation after TTO. However, >75% of reoperations were performed to remove painful hardware, and the need for reoperation seemed to have no effect on the statistically significant overall preoperative-to-postoperative improvement in VAS, Lysholm, and Kujala scores. Rates of definitive surgery for end-stage patellofemoral changes, including patellofemoral arthroplasty and total knee arthroplasty, were quite low at the weighted mean follow-up of several years after surgery, suggesting a role for TTO in avoiding arthroplasty. Although the infection rate was <1%, the rate of tibial tubercle or proximal tibia fractures was a cumulative 3.1%. Patients should be counseled on this complication risk, as treatment can require cast immobilization and weight-bearing limitations.24
The 69% proportion of women in the overall cohort and the mean (SD) age of 27.68 (10.45) years highlight the primary patient population that undergoes TTO. Compared with men, young women are more likely to have aberrant patellofemoral biomechanics, owing to their native anatomy, including their relatively larger Q-angle and TT-TG distance and thus increased lateral translational force vectors on the patella.37 In addition, more than half of patients who are having TTO underwent previous surgery on the affected knee—an indication that TTO is still not universally considered first-line in addressing patellofemoral pathology.
Limitations of the Analysis
The limitations of this analysis derive from the limitations of the included studies, which were mostly retrospective case series with relatively short follow-up. The low MCMS (<55) of all 21 studies highlights their low quality as well. These studies showed considerable heterogeneity in their reporting of specific preoperative, intraoperative, and postoperative radiographic, physical examination, and clinical outcome scores, which may be indicative of the relatively low rate of use of TTO, a procedure originally described decades ago. These studies also showed ample heterogeneity in the specific radiographic parameters or outcome scales they used to present their data. We were therefore limited in our ability to cohesively summarize and provide cumulative data points from the patients as a unified cohort. There was substantial variety in the procedures performed, surgical techniques used, concomitant pathologies addressed at time of surgery, and diagnoses treated—indicating a performance bias. This additionally precluded any significant meta-analysis within the patient cohort. A higher quality study, a randomized controlled trial, is needed to answer more definitively and completely the questions we left unanswered, including the effect on radiographic parameters, additional clinical outcomes, and patient satisfaction.
Conclusion
TTO is most commonly performed for isolated patellar instability in the presence of knee pain. Other pathologies addressed are patellofemoral osteoarthritis, and patella alta and patella baja with and without associated knee pain. TTO significantly improves knee pain and clinical outcome scores, though 21% of patients (>1 in 5) require reoperation for hardware removal. Young women with prior surgery on the affected knee are the primary patient population.
Take-Home Points
- TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects.
- Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization.
- TTO was most commonly performed for isolated patellar instability in the presence of knee pain.
- Young women with prior surgery on the affected knee made up the primary patient population for this procedure.
- While TTO significantly improves knee pain and clinical outcome scores, >1 in 5 patients required reoperation for hardware removal.
Patellofemoral pain and patellofemoral instability are common orthopedic problems. Studies have found that 30% of patients 13 to 19 years old have patellofemoral pain and that 29 in 100,000 patients 10 to 17 years old have patellofemoral instability.1-3 The reported rate of recurrence after nonoperative management of patellofemoral instability is 33%.4 Tibial tubercle osteotomy (TTO), first described by Hauser5 in 1938, is an effective treatment option for many patellofemoral disorders.
TTO indications include patellofemoral maltracking or malalignment, patellar instability, patellofemoral arthritis, and focal patellofemoral chondral defects.6 With TTO, the goal is to move the tibial tubercle in a direction that will either improve patellar tracking or offload the medial or lateral patellar facet to improve pain and function.7,8 This action typically involves anterior, medial, lateral, or distal translation of the tibial tubercle, as posteriorization can lead to increased contact forces across the patellofemoral joint, resulting in accelerated patellofemoral wear and increased pain.9
We systematically reviewed the TTO literature to identify indications, clinical outcomes, complications, and reoperations. We hypothesized that the overall complication rate and the overall reoperation rate would both be <10%.
Clinical Evaluation of Patellofemoral Pathology
Patients with patellofemoral pain often report anterior knee pain, which typically begins gradually and is often activity related. Several symptoms may be present: pain with prolonged sitting with knees bent; pain on rising from a seated position; pain or crepitus with climbing stairs; and pain during repetitive activity such as running, squatting, or jumping. Location, duration, and onset of symptoms should be elicited. Patellofemoral instability can be described as dislocation events or subluxation events; number of events, mechanisms of injury, and resulting need for reduction should be documented. As age, sex, body mass index, and physical fitness are relevant to risk of recurrence, the physician should ask about general ligamentous laxity, other joint dislocations, and prior surgical intervention. Swelling or mechanical symptoms may indicate patellofemoral joint pathology.6,10
Physical examination of patients with patellofemoral pathology begins with assessment for overall limb alignment (including resting position of patella and corresponding quadriceps angle [Q-angle]), generalized ligamentous laxity (including hypermobile joints, evaluated with Brighton criteria), overall peri-knee muscle tone and strength, effusion, and gait pattern. Knee and hip range of motion should be documented. Apprehension (Figure 1) and lack of a firm endpoint on placement of a lateralizing moment on the patella suggest prior dislocation or subluxation. Patella and surrounding anatomy must be palpated for location and severity of tenderness. Finally, patellar tilt, height, mobility, and dynamic tracking, including J-sign, are pertinent to evaluation. The J-sign for patellar tracking is positive when the patella deviates laterally as the knee moves from flexion into extension. Examination of the asymptomatic contralateral side is essential for comparison. Plain radiographs are important first-line imaging. Computed tomography or magnetic resonance imaging can be used to measure tibial tubercle-trochlear groove (TT-TG) distance. TT-TG distance of >15 mm is abnormal, and >20 mm indicates TTO is required. Advanced imaging is additionally valuable in assessing for chondral injury or trochlear dysplasia.6,10
Common TTO Procedures
TTO specifics depend on anatomy, radiographic alignment characteristics, and presence of chondral defects. Essentially, the patella is translated to offload the affected areas. Osteotomy and movement of the tibial tubercle can include anteriorization, anteromedialization, proximalization, medialization, or distalization. Lateralization or anterolateralization may be pertinent to revision if an osteotomy direction results in overcorrection of tuberosity position. Anteriorization (Figures 2A-2C) does not have a role in patellofemoral instability, but can unload areas of excessive patellar chondral force concentration at the central or proximal patella by increasing the angle between the patellar and quadriceps tendons and thereby decreasing the joint reaction forces. Straight medialization (Figures 3A, 3B) offloads lateral patellar chondral injury and may decrease lateral instability. Distalization (Figures 4A-4C) can correct for patella alta in the setting of patellar instability and allows earlier engagement of the patella in the trochlea to increase osseous restraint to lateral translation.6
Anteromedialization (Figure 5) is indicated in patients with a normal proximal and medial patellar chondral surface and a laterally positioned patella leading to alteration of the contact area in the trochlear groove and resulting pain, lateral patellar or trochlear chondral disease, or instability. Osteotomy angle can provide varied medialization through consistent slope and anteriorization. For example, a 60° slope osteotomy provides 9 mm of medialization with 15 mm of anteriorization.6 The procedure, similar to the additional TTO operations, begins with a lateral parapatellar incision that is extended distal to the tibial tubercle and anterior over the crest. The soft tissues around the tubercle are released to allow mobilization. Variable osteotomy jigs allow for different slope cuts for more medialization or anteriorization, based on preoperative findings. The osteotomy cuts are started with a thin oscillating blade (Figure 6) and finished with an osteotome. The tubercle fragment (Figure 7) is shifted and provisionally fixed with a Kirschner wire before being drilled and fixated with two 4.5-mm countersunk cortical screws (Figures 8, 9A-9B). Locally harvested corticocancellous bone can help anteriorize the tubercle block. Osteotomy specifics allow for corresponding anatomical translations of the TTO to address the preoperative pathology.
Methods
Search Strategy and Data Collection
We searched the PubMed (Medline) database for all English-language TTO studies published between database inception and April 9, 2015. After PROSPERO registration, and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we used the algorithm (“tibial” AND “tubercle” AND “osteotomy”) NOT (“total” AND “knee” AND “arthroplasty”) to search the literature. Inclusion criteria included level I-IV studies on TTO indications, operative findings, and outcomes. Exclusion criteria were non-English studies, unpublished studies, level V evidence, letters to the editor, editorials, review articles, basic science articles, technique articles, revision procedures, articles without clinical outcomes, and conference proceeding abstracts. Studies that reported on duplicate populations were included only with the most recent available clinical outcomes. All abstracts were reviewed in duplicate by Dr. Levy and Dr. Rao and assessed with respect to the criteria outlined. Then the same authors performed full-text reviews of eligible studies before including these studies in the systematic review. They also manually checked the references in study articles to identify additional studies for possible inclusion in the review. A standardized form created by the authors at the start of the review was used to extract data (Table 1).
Assessment of Study Quality
The quality of each TTO study in the review was assessed with a modified Coleman methodology score (MCMS), which ranges from 0 to 100. A study with an MCMS of <55 points is considered a poor-quality study.11
Data Synthesis and Statistical Analysis
Given that most of the included studies were level IV, a formal meta-analysis was not indicated. In this article, we report categorical data as frequencies with percentages and preoperative and postoperative continuous data as means (SDs), with weighted means based on number of patients in each study, where applicable. We used 2-tailed t tests for comparisons made with the free Meta-Analysis Calculator and Grapher (http://www.healthstrategy.com/meta/meta.pl ). Statistical significance was set at P < .05.
Results
Search Results and Included Studies
Twenty-one studies (976 patients, 1055 knees) were included in the analysis (Figure 10; Table 2).12-32 These studies were published between 1986 and 2013. There were 18 level IV studies (85.7%), 3 level III studies (14%), and no level I or II studies. Better quality studies had a mean (SD) MCMS of 19.8 (8.2), well under the 55-point cutoff. In the 16 studies that reported sex, women accounted for 69% of the population. Weighted mean (SD) age was 27.68 (10.45) years (range, 12-77 years) (18 studies reporting).
Only 1 study provided preoperative body mass index (27 kg/m2). There were 55.35% of patients who had prior surgery on the affected knee (6 studies reporting).
Preoperative Data
Preoperative pathologic, radiographic, and clinical scoring data were scarcely reported and nonuniform (Table 2). The most common pathology treated with TTO was isolated patellofemoral instability (746/1055 patients, 70.7%). The other pathologies addressed were isolated patellofemoral osteoarthritis/chondromalacia patellae (143, 13.6%), patellofemoral instability with patella alta (61, 5.8%), patellofemoral instability with patellofemoral osteoarthritis (45, 4.3%), isolated patella baja (41, 3.9%), isolated patella alta (19, 1.8%), and patellofemoral osteoarthritis with patella baja (2, 0.2%). Five hundred fifty-five patients (53%) had a preoperative complaint that included knee pain, and 809 (77%) reported preoperative patellar laxity or instability events. The imaging data reported were Q-angle, Insall-Salvati ratio, Caton-Deschamps index, Blackburne-Peel ratio, Outerbridge osteoarthritis grade, and TT-TG distance. Preoperative clinical scoring data most prominently included a visual analog scale (VAS) score of 70.50 (4 studies reporting), a Lysholm score of 59.19 (5 studies), and a Kujala score of 41.16 (4 studies). Shelbourne-Trumper and Cox-Insall scores were reported in 1 and 2 studies, respectively.
Operative Characteristics
Of the 21 studies, 12 reported only on patients who had TTO performed in isolation; in the other 9 studies, cohorts included patients who underwent concurrent procedures. In the 17 studies (856 patients) that listed numbers of patients who underwent specific concomitant procedures, 715 patients (83.5%) underwent an isolated TTO procedure, and the other 141 (16.5%) underwent either concomitant lateral femoral trochleoplasty, arthroscopic drilling of chondral lesions, patellar shaving chondroplasty, partial meniscectomy or concomitant meniscal repair, intra-articular loose body removal, and/or lateral release with or without medial plication.
Twenty studies reported specifics on the intraoperative direction of the tibial bone block osteotomy (Table 3). In most cases (50.8%), anteromedial translation (anteromedialization) was performed; anteriorization was performed in 18.7% of cases, medialization in 9.6%, medial and distal translation in 7.2%, a “triple” (anteriorization, medialization, proximalization) in 6%, isolated distalization in 2.8%, and proximalization in 1.6%. The remaining 2.8% of procedure specifics were not identified.
Postoperative Data
Table 4 lists the overall cohort’s postoperative radiographic, clinical outcome scoring, and complications data. Fifteen studies reported follow-up of >2 years. As with the preoperative data, radiographic and clinical scoring data were relatively nonuniform; some numeric data, however, should be highlighted. Statistical analysis allowed for comparison of preoperative-postoperative VAS, Lysholm, and Kujala scores, each of which was significantly higher after surgery (P < .001). Seven studies reported an overall clinical outcome rating, with the cumulative majority of patients reporting good (37.9%) or excellent (39.2%) results.
There was a cumulative total of 79 complications (8% of cohort): 17 recurrent patellar dislocations (1.9%), 4 recurrent patellar subluxations (0.4%), 10 wound complications (1.0%), 2 intraoperative complications (0.2%), 14 tibial tubercle fractures (1.3%), 19 proximal tibia fractures (1.8%), 4 cases of anterior knee pain (0.4%), 4 cases of neuropraxia (0.4%), and 5 infections (0.5%). Of note, 219 knees (21%) required reoperation, but 170 (16.3%) of these were for painful hardware removal. Sixteen knees (1.5%) required revision TTO, 1 (0.1%) required subsequent high tibial osteotomy, 2 (0.2%) underwent patellofemoral arthroplasty for advanced arthritic changes, and 5 (0.5%) underwent total knee arthroplasty for advanced arthritic changes.
Studies With TTO Performed in Isolation
Twelve studies reported outcomes of isolated TTO procedures. In the 638 patients who underwent isolated TTO, the pathologies addressed were instability/laxity (429 patients, 67%), patellofemoral osteoarthritis (74, 12%), patella alta with instability (61, 10%), patellofemoral osteoarthritis with instability (31, 5%), patella baja (24, 4%), and patella alta (19, 3%). Pain was a preoperative issue in 289 (45%) of these patients and instability in 472 (74%).
Only 2.8% of patients experienced postoperative patellar dislocation events. Of the 12 studies, 2 reported VAS scores (34-point weighted mean improvement, 65 points before surgery to 31 after surgery), 3 reported Lysholm scores (30-point improvement, from 60 to 90), and 2 reported Kujala scores (21-point improvement, from 46 to 67).
Complication rates for this isolated-TTO pooled cohort of patients were 1.2% for revision TTOs, 0.5% for wound complications, 0.8% for tibial tubercle fractures, and 1.9% for proximal tibia fractures. In total, 16% of patients required hardware removal after surgery.
Discussion
This study found that TTO improved patient pain and clinical outcome scores despite having a high (16%) rate of reoperation for painful hardware in patients with preoperative pain or instability, or with patellofemoral osteoarthritis or aberrant patellar anatomy. This reoperation rate and the overall complication rate both exceeded our hypothesized 10% cumulative rate. However, <1% of patients required conversion to a definitive end-stage surgery (patellofemoral arthroplasty or total knee arthroplasty) by final follow-up, and the rates of comorbidities (anterior knee pain, wound infection, recurrent patellar subluxation/dislocation, tibial fracture) were relatively low.
Patellofemoral disorders are common in the general population and a frequent primary complaint on presentation to orthopedic offices. Having a thorough understanding of knee joint biomechanics is imperative when trying to determine whether surgery is appropriate for these complaints and how to proceed. Extensor mechanism abnormalities, including high lateral force vectors (or larger TT-TG distances) and excessive patellar tilt, can affect alignment and increase the risk for patellofemoral dislocations, patellofemoral anterior- based knee pains, and chondral lesions. Patella alta, an elevated patella, risks increased contact stresses between the patella and the trochlear groove33 and decreases the osseous constraints that inhibit dislocation of the patella with physiologic flexion of the joint.34 With TTO, the change in tuberosity position can alter angles in the extensor mechanism and thereby decrease joint reaction forces and patellofemoral contact area forces.35,36
Although its use began as an option for combating patellar instability events in patients with predisposed patellofemoral kinematics,5 TTO has evolved in its therapeutic uses to include offloading patellar and trochlear focal chondral lesions and slowing progression of patellofemoral arthritis. Multiple iterations and modifications of the procedure have involved distal and medial transfer of the tibial tuberosity, medialization alone, concurrent anterior and medial elevation of the tuberosity, and proximal or distal transfers, depending on the pathology being corrected. Although TTO is highly versatile in treating multiple patellofemoral joint pathologies, this study found that its primary indication continues to be patellar instability, with anteromedialization as the most common direction of tubercle transfer in support of the medial structures providing the medial force vector that keeps the patella in place. These medial structures include the medial patellofemoral ligament, the vastus medialis obliquus, the medial patellotibial ligament, and the medial retinaculum.
Also notable was the relatively high rate of reoperation after TTO. However, >75% of reoperations were performed to remove painful hardware, and the need for reoperation seemed to have no effect on the statistically significant overall preoperative-to-postoperative improvement in VAS, Lysholm, and Kujala scores. Rates of definitive surgery for end-stage patellofemoral changes, including patellofemoral arthroplasty and total knee arthroplasty, were quite low at the weighted mean follow-up of several years after surgery, suggesting a role for TTO in avoiding arthroplasty. Although the infection rate was <1%, the rate of tibial tubercle or proximal tibia fractures was a cumulative 3.1%. Patients should be counseled on this complication risk, as treatment can require cast immobilization and weight-bearing limitations.24
The 69% proportion of women in the overall cohort and the mean (SD) age of 27.68 (10.45) years highlight the primary patient population that undergoes TTO. Compared with men, young women are more likely to have aberrant patellofemoral biomechanics, owing to their native anatomy, including their relatively larger Q-angle and TT-TG distance and thus increased lateral translational force vectors on the patella.37 In addition, more than half of patients who are having TTO underwent previous surgery on the affected knee—an indication that TTO is still not universally considered first-line in addressing patellofemoral pathology.
Limitations of the Analysis
The limitations of this analysis derive from the limitations of the included studies, which were mostly retrospective case series with relatively short follow-up. The low MCMS (<55) of all 21 studies highlights their low quality as well. These studies showed considerable heterogeneity in their reporting of specific preoperative, intraoperative, and postoperative radiographic, physical examination, and clinical outcome scores, which may be indicative of the relatively low rate of use of TTO, a procedure originally described decades ago. These studies also showed ample heterogeneity in the specific radiographic parameters or outcome scales they used to present their data. We were therefore limited in our ability to cohesively summarize and provide cumulative data points from the patients as a unified cohort. There was substantial variety in the procedures performed, surgical techniques used, concomitant pathologies addressed at time of surgery, and diagnoses treated—indicating a performance bias. This additionally precluded any significant meta-analysis within the patient cohort. A higher quality study, a randomized controlled trial, is needed to answer more definitively and completely the questions we left unanswered, including the effect on radiographic parameters, additional clinical outcomes, and patient satisfaction.
Conclusion
TTO is most commonly performed for isolated patellar instability in the presence of knee pain. Other pathologies addressed are patellofemoral osteoarthritis, and patella alta and patella baja with and without associated knee pain. TTO significantly improves knee pain and clinical outcome scores, though 21% of patients (>1 in 5) require reoperation for hardware removal. Young women with prior surgery on the affected knee are the primary patient population.
1. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7- year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64(4):393-400.
2. Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br. 1984;66(5):685-693.
3. Mehta VM, Inoue M, Nomura E, Fithian DC. An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc. 2007;15(2):78-81.
4. Erickson BJ, Mascarenhas R, Sayegh ET, et al. Does operative treatment of first-time patellar dislocations lead to increased patellofemoral stability? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31(6):1207-1215.
5. Hauser E. Total tendon transplant for slipping patella. Surg Gynecol Obstet. 1938;66:199-214.
6. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
7. Hall MJ, Mandalia VI. Tibial tubercle osteotomy for patello-femoral joint disorders. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):855-861.
8. Grawe B, Stein BS. Tibial tubercle osteotomy: indication and techniques. J Knee Surg. 2015;28(4):279-284.
9. Fulkerson JP. Disorders of the Patellofemoral Joint. 4th ed. Baltimore, MD: Williams & Wilkins; 1997.
10. Koh JL, Stewart C. Patellar instability. Clin Sports Med. 2014;33(3):461-476.
11. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. 2000;10(1):2-11.
12. Al-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Rel Res. 2002;(396):152-162.
13. Atkinson HD, Bailey CA, Anand S, Johal P, Oakeshott RD. Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees. Arch Orthop Trauma Surg. 2012;132(4):437-445.
14. Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop. 2010;34(2):305-309.
15. Dantas P, Nunes C, Moreira J, Amaral LB. Antero-medialisation of the tibial tubercle for patellar instability. Int Orthop. 2005;29(6):390-391.
16. Drexler M, Dwyer T, Marmor M, Sternheim A, Cameron HU, Cameron JC. The treatment of acquired patella baja with proximalize the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc. 2013;21(11):2578-2583.
17. Eager MR, Bader DA, Kelly JD 4th, Moyer RA. Delayed fracture of the tibia following anteromedialization osteotomy of the tibial tubercle: a report of 5 cases. Am J Sports Med. 2004;32(4):1041-1048.
18. Ebinger TP, Boezaart A, Albright JP. Modifications of the Fulkerson osteotomy: a pilot study assessment of a novel technique of dynamic intraoperative determination of the adequacy of tubercle transfer. Iowa Orthop J. 2007;27:61-64.
19. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;18(5):490-498.
20. Heatley FW, Allen PR, Patrick JH. Tibial tubercle advancement for anterior knee pain: a temporary or permanent solution. Clin Orthop Relat Res. 1986;(208):216-225.
21. Hirsh DM, Reddy DK. Experience with Maquet anterior tibial tubercle advancement for patellofemoral arthralgia. Clin Orthop Relat Res. 1980;(148):136-139.
22. Jack CM, Rajaratnam SS, Khan HO, Keast-Butler O, Butler-Manuel PA, Heatley FW. The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: a five-year prospective study. Bone Joint Res. 2012;1(8):167-173.
23. Koëter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar maltracking: results at two years. J Bone Joint Surg Br. 2007;89(2):180-185.
24. Luhmann SJ, Fuhrhop S, O’Donnell JC, Gordon JE. Tibial fractures after tibial tubercle osteotomies for patellar instability: a comparison of three osteotomy configurations. J Child Orthop. 2011;5(1):19-26.
25. Naranja RJ Jr, Reilly PJ, Kuhlman JR, Haut E, Torg JS. Long-term evaluation of the Elmslie-Trillat-Maquet procedure for patellofemoral dysfunction. Am J Sports Med. 1996;24(6):779-784.
26. Naveed MA, Ackroyd CE, Porteous AJ. Long-term (ten- to 15-year) outcome of arthroscopically assisted Elmslie-Trillat tibial tubercle osteotomy. Bone Joint J. 2013;95(4):478-485.
27. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009;37(7):1288-1300.
28. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP. Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am J Sports Med. 1997;25(4):533-537.
29. Shen HC, Chao KH, Huang GS, Pan RY, Lee CH. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med. 2007;35(12):2101-2108.
30. Stetson WB, Friedman MJ, Fulkerson JP, Cheng M, Buuck D. Fracture of the proximal tibia with immediate weightbearing after a Fulkerson osteotomy. Am J Sports Med. 1997;25(4):570-574.
31. Valenzuela L, Nemtala F, Orrego M, et al. Treatment of patellofemoral chondropathy with the Bandi tibial tubercle osteotomy: more than 10 years follow-up. Knee. 2011;18(2):94-97.
32. Wang CJ, Wong T, Ko JY, Siu KK. Triple positioning of tibial tubercle osteotomy for patellofemoral disorders. Knee. 2014;21(1):133-137.
33. Luyckx T, Didden K, Vandenneucker H, Labey L, Innocenti B, Bellemans J. Is there a biomechanical explanation for anterior knee pain in patients with patella alta? Influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg Br. 2009;91(3):344-350.
34. Mayer C, Magnussen RA, Servien E, et al. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Am J Sports Med. 2012;40(2):346-351.
35. Maquet P. Advancement of the tibial tuberosity. Clin Orthop Relat Res. 1976;(115):225-230.
36. Lewallen DG, Riegger CL, Myers ER, Hayes WC. Effects of retinacular release and tibial tubercle elevation in patellofemoral degenerative joint disease. J Orthop Res. 1990;8(6):856-862.
37. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence, I: measurements of incongruence. Clin Orthop Relat Res. 1983;(176):217-224.
1. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7- year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64(4):393-400.
2. Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br. 1984;66(5):685-693.
3. Mehta VM, Inoue M, Nomura E, Fithian DC. An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc. 2007;15(2):78-81.
4. Erickson BJ, Mascarenhas R, Sayegh ET, et al. Does operative treatment of first-time patellar dislocations lead to increased patellofemoral stability? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31(6):1207-1215.
5. Hauser E. Total tendon transplant for slipping patella. Surg Gynecol Obstet. 1938;66:199-214.
6. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
7. Hall MJ, Mandalia VI. Tibial tubercle osteotomy for patello-femoral joint disorders. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):855-861.
8. Grawe B, Stein BS. Tibial tubercle osteotomy: indication and techniques. J Knee Surg. 2015;28(4):279-284.
9. Fulkerson JP. Disorders of the Patellofemoral Joint. 4th ed. Baltimore, MD: Williams & Wilkins; 1997.
10. Koh JL, Stewart C. Patellar instability. Clin Sports Med. 2014;33(3):461-476.
11. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. 2000;10(1):2-11.
12. Al-Sayyad MJ, Cameron JC. Functional outcome after tibial tubercle transfer for the painful patella alta. Clin Orthop Rel Res. 2002;(396):152-162.
13. Atkinson HD, Bailey CA, Anand S, Johal P, Oakeshott RD. Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees. Arch Orthop Trauma Surg. 2012;132(4):437-445.
14. Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop. 2010;34(2):305-309.
15. Dantas P, Nunes C, Moreira J, Amaral LB. Antero-medialisation of the tibial tubercle for patellar instability. Int Orthop. 2005;29(6):390-391.
16. Drexler M, Dwyer T, Marmor M, Sternheim A, Cameron HU, Cameron JC. The treatment of acquired patella baja with proximalize the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc. 2013;21(11):2578-2583.
17. Eager MR, Bader DA, Kelly JD 4th, Moyer RA. Delayed fracture of the tibia following anteromedialization osteotomy of the tibial tubercle: a report of 5 cases. Am J Sports Med. 2004;32(4):1041-1048.
18. Ebinger TP, Boezaart A, Albright JP. Modifications of the Fulkerson osteotomy: a pilot study assessment of a novel technique of dynamic intraoperative determination of the adequacy of tubercle transfer. Iowa Orthop J. 2007;27:61-64.
19. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;18(5):490-498.
20. Heatley FW, Allen PR, Patrick JH. Tibial tubercle advancement for anterior knee pain: a temporary or permanent solution. Clin Orthop Relat Res. 1986;(208):216-225.
21. Hirsh DM, Reddy DK. Experience with Maquet anterior tibial tubercle advancement for patellofemoral arthralgia. Clin Orthop Relat Res. 1980;(148):136-139.
22. Jack CM, Rajaratnam SS, Khan HO, Keast-Butler O, Butler-Manuel PA, Heatley FW. The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: a five-year prospective study. Bone Joint Res. 2012;1(8):167-173.
23. Koëter S, Diks MJ, Anderson PG, Wymenga AB. A modified tibial tubercle osteotomy for patellar maltracking: results at two years. J Bone Joint Surg Br. 2007;89(2):180-185.
24. Luhmann SJ, Fuhrhop S, O’Donnell JC, Gordon JE. Tibial fractures after tibial tubercle osteotomies for patellar instability: a comparison of three osteotomy configurations. J Child Orthop. 2011;5(1):19-26.
25. Naranja RJ Jr, Reilly PJ, Kuhlman JR, Haut E, Torg JS. Long-term evaluation of the Elmslie-Trillat-Maquet procedure for patellofemoral dysfunction. Am J Sports Med. 1996;24(6):779-784.
26. Naveed MA, Ackroyd CE, Porteous AJ. Long-term (ten- to 15-year) outcome of arthroscopically assisted Elmslie-Trillat tibial tubercle osteotomy. Bone Joint J. 2013;95(4):478-485.
27. Paulos L, Swanson SC, Stoddard GJ, Barber-Westin S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009;37(7):1288-1300.
28. Pidoriano AJ, Weinstein RN, Buuck DA, Fulkerson JP. Correlation of patellar articular lesions with results from anteromedial tibial tubercle transfer. Am J Sports Med. 1997;25(4):533-537.
29. Shen HC, Chao KH, Huang GS, Pan RY, Lee CH. Combined proximal and distal realignment procedures to treat the habitual dislocation of the patella in adults. Am J Sports Med. 2007;35(12):2101-2108.
30. Stetson WB, Friedman MJ, Fulkerson JP, Cheng M, Buuck D. Fracture of the proximal tibia with immediate weightbearing after a Fulkerson osteotomy. Am J Sports Med. 1997;25(4):570-574.
31. Valenzuela L, Nemtala F, Orrego M, et al. Treatment of patellofemoral chondropathy with the Bandi tibial tubercle osteotomy: more than 10 years follow-up. Knee. 2011;18(2):94-97.
32. Wang CJ, Wong T, Ko JY, Siu KK. Triple positioning of tibial tubercle osteotomy for patellofemoral disorders. Knee. 2014;21(1):133-137.
33. Luyckx T, Didden K, Vandenneucker H, Labey L, Innocenti B, Bellemans J. Is there a biomechanical explanation for anterior knee pain in patients with patella alta? Influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg Br. 2009;91(3):344-350.
34. Mayer C, Magnussen RA, Servien E, et al. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Am J Sports Med. 2012;40(2):346-351.
35. Maquet P. Advancement of the tibial tuberosity. Clin Orthop Relat Res. 1976;(115):225-230.
36. Lewallen DG, Riegger CL, Myers ER, Hayes WC. Effects of retinacular release and tibial tubercle elevation in patellofemoral degenerative joint disease. J Orthop Res. 1990;8(6):856-862.
37. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence, I: measurements of incongruence. Clin Orthop Relat Res. 1983;(176):217-224.
Biceps Tenodesis: An Evolution of Treatment
Take-Home Points
- The LHB tendon has been shown to be a significant pain generator in the shoulder.
- At our institution, the number of LHB tenodeses significantly increased from 2004 to 2014.
- The age of patients who underwent a LHB tenodesis did not change significantly over the study period.
- Furthermore, the percentage of shoulder procedures that involved a LHB tenodesis significantly increased over the study period.
- Biceps tenodesis has become a more common procedure to treat shoulder pathology.
Although the exact function of the long head of the biceps (LHB) tendon is not completely understood, it is accepted that the LHB tendon can be a significant source of pain within the shoulder.1-4 Patients with symptoms related to biceps pathology often present with anterior shoulder pain that worsens with flexion and supination of the affected elbow and wrist.5 Although the sensitivity and specificity of physical examination maneuvers have been called into question, special tests have been developed to aid in the diagnosis of tendonitis of the LHB. These tests include the Speed, Yergason, bear hug, and uppercut tests as well as the O’Brien test (cross-body adduction).6,7 Recent studies have found LHB pathology in 45% of patients who undergo rotator cuff repair and in 63% of patients with a subscapularis tear.8,9
Pathology of the LHB tendon, including superior labrum anterior to posterior (SLAP) tears, can be treated in many ways.5,10,11 Options include SLAP repair, biceps tenodesis, débridement, and biceps tenotomy.11,12 Results of SLAP repairs have been less than optimal, but biceps tenodesis has been effective, and avoids the issue of cramping as can be seen with biceps tenotomy and débridement.10,12,13 Surgical methods for biceps tenodesis include open subpectoral and all-arthroscopic.11,12 Both methods have had good, reliable outcomes, but the all-arthroscopic technique is relatively new.11,12,14We conducted a study to determine LHB tenodesis trends, including patient age at time of surgery. We used surgical data from fellowship-trained sports or shoulder/elbow orthopedic surgeons at a busy subspecialty-based shoulder orthopedic practice. We hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis.
Methods
Our Institutional Review Board exempted this study. To determine the number of LHB tenodesis procedures performed at our institution, overall and in comparison with other common arthroscopic shoulder procedures, we queried the surgical database of 4 fellowship-trained orthopedic surgeons (shoulder/elbow, Drs. Nicholson and Cole; sports, Drs. Romeo and Verma) for the period January 1, 2004 to December 31, 2014. We used Current Procedural Terminology (CPT) code 23430 to determine the number of LHB tenodesis cases, as the surgeons primarily perform an open subpectoral biceps tenodesis. Patient age at time of surgery and the date of surgery were recorded. All patients who underwent LHB tenodesis between January 1, 2004 and December 31, 2014 were included. Number of procedures performed each year by each surgeon was recorded, as were concomitant procedures performed at the same time as the LHB tenodesis. To get the denominator (and reference point) for the number of arthroscopic shoulder surgeries performed by these 4 surgeons during the study period, and thereby determine the rate of LHB tenodesis, we selected the most common shoulder arthroscopy CPT codes used in our practice: 23430, 29806, 29807, 29822, 29823, 29825, 29826, and 29827. For a patient who underwent multiple procedures on the same day (multiple CPT codes entered on the same day), only one code was counted for that day. If 23430 was among the codes, it was included, and the case was placed in the numerator; if 23430 was not among the codes, the case was placed in the denominator.
The Arthroscopy Association of North America provides descriptions for the CPT codes: 23430 (tenodesis of long tendon of biceps), 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy), 29807 (arthroscopy, shoulder, surgical; repair of SLAP lesion), 29822 (arthroscopy, shoulder, surgical; débridement, limited), 29823 (arthroscopy, shoulder, surgical; débridement, extensive), 29825 (arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation), 29826 (arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release), and 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair).
For analysis, we divided the data into total number of arthroscopic shoulder procedures performed by each surgeon each year and number of LHB tenodesis procedures performed by each surgeon each year. Total number of patients who had an arthroscopic procedure was used to create a denominator, and number of LHB tenodesis procedures showed the percentage of arthroscopic shoulder surgery patients who underwent LHB tenodesis. (All patients who undergo biceps tenodesis also have, at the least, diagnostic shoulder arthroscopy with or without tenotomy; if the tendon is ruptured, tenotomy is unnecessary.)
Descriptive statistics were calculated as means (SDs) for continuous variables and as frequencies with percentages for categorical variables. Linear regression analysis was used to determine whether the number of LHB tenodesis procedures changed during the study period and whether patient age changed over time. Significance was set at P < .05.
Results
Of the 7640 patients who underwent arthroscopic shoulder procedures between 2004 and 2014, 2125 had LHB tenodesis (CPT code 23430).
Discussion
Tenodesis has become a common treatment option for several pathologic shoulder conditions involving the LHB tendon.5 We set out to determine trends in LHB tenodesis at a subspecialty-focused shoulder orthopedic practice and hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis. Our hypotheses were confirmed: The number of LHB tenodesis cases increased significantly without a significant change in patient age.
Treatment options for LHB pathology and SLAP tears include simple tenotomy, débridement, open biceps tenodesis, and arthroscopic tenodesis.11,12,15
Recent evidence has called into question the results of SLAP repairs and suggested biceps tenodesis may be a better treatment option for SLAP tears.10,13,21 Studies have found excellent outcomes with open subpectoral biceps tenodesis in the treatment of SLAP tears, and others have found better restoration of pitchers’ thoracic rotation with open subpectoral biceps tenodesis than with SLAP repair.13,14 Similarly, comparison studies have largely favored biceps tenodesis over SLAP repair, particularly in patients older than 35 years to 40 years.22 Given these results, it is not surprising that, querying the American Board of Orthopaedic Surgeons (ABOS) part II database for isolated SLAP lesions treated between 2002 and 2011, Patterson and colleagues23 found the percentage of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), whereas the percentage of biceps tenodesis procedures increased from 1.9% to 18.8% (P < .0001), indicating the realization of improved outcomes with LHB tenodesis in the treatment of SLAP tears. On the other hand, in the ABOS part II database for the period 2003 to 2008, Weber and colleagues24 found that, despite a decrease in the percentage of SLAP repairs, total number of SLAP repairs increased from 9.4% to 10.1% (P = .0163). According to our study results, the number of SLAP repairs is decreasing over time, whereas the number of LHB tenodesis procedures is continuing to rise. The practice patterns seen in our study correlate with those in previous studies of the treatment of SLAP tears: good results in tenodesis groups and poor results in SLAP repair groups.10,13Werner and colleagues25 recently used the large PearlDiver database, which includes information from both private payers and Medicare, to determine overall LHB tenodesis trends in the United States for the period 2008 to 2011. Over those years, the incidence of LHB tenodesis increased 1.7-fold, and the rate of arthroscopic LHB tenodesis increased significantly more than the rate of open LHB tenodesis. These results are similar to ours in that the number of LHB tenodesis cases increased significantly over time. However, as the overwhelming majority of patients in our practice undergo open biceps tenodesis, the faster rate of growth in the arthroscopic cohort relative to the open cohort cannot be assessed. Additional randomized studies comparing biceps tenodesis, both open and arthroscopic, with SLAP repair are needed to properly determine the superiority of LHB tenodesis over SLAP repair.
One strength of this database study was the number of patients: more than 7000, 2125 of whom underwent biceps tenodesis performed by 1 of 4 fellowship-trained orthopedic surgeons. There were several study limitations. First, because the original diagnoses were not recorded, it was unclear exactly which pathologies were treated with tenodesis, limiting our ability to make recommendations regarding treatment trends for specific pathologies. Similarly, we did not assess outcome variables, which would have allowed us to draw conclusions about the effectiveness of the biceps tenodesis procedures. Furthermore, some procedures may have been coded incorrectly, and therefore some patients may have been erroneously included or excluded. In addition, using data from only one institution may have introduced bias into our conclusions, though the results are consistent with national trends. Finally, there was some variability among the 4 surgeons in the number of LHB tenodesis procedures performed, and this variability may have confounded results, though these surgeons treat biceps pathology in similar ways.
Am J Orthop. 2017;46(4):E219-E223. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: implications for restoring physiological length–tension relation during biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28(10):1352-1358.
2. Ejnisman B, Monteiro GC, Andreoli CV, de Castro Pochini A. Disorder of the long head of the biceps tendon. Br J Sports Med. 2010;44(5):347-354.
3. Mellano CR, Shin JJ, Yanke AB, Verma NN. Disorders of the long head of the biceps tendon. Instr Course Lect. 2015;64:567-576.
4. Szabo I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Med Arthrosc Rev. 2008;16(3):180-186.
5. Harwin SF, Birns ME, Mbabuike JJ, Porter DA, Galano GJ. Arthroscopic tenodesis of the long head of the biceps. Orthopedics. 2014;37(11):743-747.
6. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20(3):231-236.
7. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37(9):1840-1847.
8. Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23(1):73-80.
9. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy. 2008;24(12):1381-1389.
10. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013;41(4):880-886.
11. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Am J Sports Med. 2015;43(5):1077-1083.
12. Delle Rose G, Borroni M, Silvestro A, et al. The long head of biceps as a source of pain in active population: tenotomy or tenodesis? A comparison of 2 case series with isolated lesions. Musculoskelet Surg. 2012;96(suppl 1):S47-S52.
13. Chalmers PN, Trombley R, Cip J, et al. Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears. Am J Sports Med. 2014;42(12):2825-2836.
14. Gupta AK, Chalmers PN, Klosterman EL, et al. Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear. Orthopedics. 2015;38(1):e48-e53.
15. Ge H, Zhang Q, Sun Y, Li J, Sun L, Cheng B. Tenotomy or tenodesis for the long head of biceps lesions in shoulders: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0121286.
16. Kaback LA, Gowda AL, Paller D, Green A, Blaine T. Long head biceps tenodesis with a knotless cinch suture anchor: a biomechanical analysis. Arthroscopy. 2015;31(5):831-835.
17. Kany J, Guinand R, Amaravathi RS, Alassaf I. The keyhole technique for arthroscopic tenodesis of the long head of the biceps tendon. In vivo prospective study with a radio-opaque marker. Orthop Traumatol Surg Res. 2015;101(1):31-34.
18. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. 2008;36(10):1922-1929.
19. Provencher MT, LeClere LE, Romeo AA. Subpectoral biceps tenodesis. Sports Med Arthrosc Rev. 2008;16(3):170-176.
20. Erickson BJ, Jain A, Abrams GD, et al. SLAP lesions: trends in treatment. Arthroscopy. 2016;32(6):976-981.
21. Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med. 2015;43(5):1274-1282.
22. Denard PJ, Ladermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics. 2014;37(3):e292-e297.
23. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of Orthopaedic Surgery certification examination database. Am J Sports Med. 2014;42(8):1904-1910.
24. Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40(7):1538-1543.
25. Werner BC, Brockmeier SF, Gwathmey FW. Trends in long head biceps tenodesis. Am J Sports Med. 2015;43(3):570-578.
Take-Home Points
- The LHB tendon has been shown to be a significant pain generator in the shoulder.
- At our institution, the number of LHB tenodeses significantly increased from 2004 to 2014.
- The age of patients who underwent a LHB tenodesis did not change significantly over the study period.
- Furthermore, the percentage of shoulder procedures that involved a LHB tenodesis significantly increased over the study period.
- Biceps tenodesis has become a more common procedure to treat shoulder pathology.
Although the exact function of the long head of the biceps (LHB) tendon is not completely understood, it is accepted that the LHB tendon can be a significant source of pain within the shoulder.1-4 Patients with symptoms related to biceps pathology often present with anterior shoulder pain that worsens with flexion and supination of the affected elbow and wrist.5 Although the sensitivity and specificity of physical examination maneuvers have been called into question, special tests have been developed to aid in the diagnosis of tendonitis of the LHB. These tests include the Speed, Yergason, bear hug, and uppercut tests as well as the O’Brien test (cross-body adduction).6,7 Recent studies have found LHB pathology in 45% of patients who undergo rotator cuff repair and in 63% of patients with a subscapularis tear.8,9
Pathology of the LHB tendon, including superior labrum anterior to posterior (SLAP) tears, can be treated in many ways.5,10,11 Options include SLAP repair, biceps tenodesis, débridement, and biceps tenotomy.11,12 Results of SLAP repairs have been less than optimal, but biceps tenodesis has been effective, and avoids the issue of cramping as can be seen with biceps tenotomy and débridement.10,12,13 Surgical methods for biceps tenodesis include open subpectoral and all-arthroscopic.11,12 Both methods have had good, reliable outcomes, but the all-arthroscopic technique is relatively new.11,12,14We conducted a study to determine LHB tenodesis trends, including patient age at time of surgery. We used surgical data from fellowship-trained sports or shoulder/elbow orthopedic surgeons at a busy subspecialty-based shoulder orthopedic practice. We hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis.
Methods
Our Institutional Review Board exempted this study. To determine the number of LHB tenodesis procedures performed at our institution, overall and in comparison with other common arthroscopic shoulder procedures, we queried the surgical database of 4 fellowship-trained orthopedic surgeons (shoulder/elbow, Drs. Nicholson and Cole; sports, Drs. Romeo and Verma) for the period January 1, 2004 to December 31, 2014. We used Current Procedural Terminology (CPT) code 23430 to determine the number of LHB tenodesis cases, as the surgeons primarily perform an open subpectoral biceps tenodesis. Patient age at time of surgery and the date of surgery were recorded. All patients who underwent LHB tenodesis between January 1, 2004 and December 31, 2014 were included. Number of procedures performed each year by each surgeon was recorded, as were concomitant procedures performed at the same time as the LHB tenodesis. To get the denominator (and reference point) for the number of arthroscopic shoulder surgeries performed by these 4 surgeons during the study period, and thereby determine the rate of LHB tenodesis, we selected the most common shoulder arthroscopy CPT codes used in our practice: 23430, 29806, 29807, 29822, 29823, 29825, 29826, and 29827. For a patient who underwent multiple procedures on the same day (multiple CPT codes entered on the same day), only one code was counted for that day. If 23430 was among the codes, it was included, and the case was placed in the numerator; if 23430 was not among the codes, the case was placed in the denominator.
The Arthroscopy Association of North America provides descriptions for the CPT codes: 23430 (tenodesis of long tendon of biceps), 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy), 29807 (arthroscopy, shoulder, surgical; repair of SLAP lesion), 29822 (arthroscopy, shoulder, surgical; débridement, limited), 29823 (arthroscopy, shoulder, surgical; débridement, extensive), 29825 (arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation), 29826 (arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release), and 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair).
For analysis, we divided the data into total number of arthroscopic shoulder procedures performed by each surgeon each year and number of LHB tenodesis procedures performed by each surgeon each year. Total number of patients who had an arthroscopic procedure was used to create a denominator, and number of LHB tenodesis procedures showed the percentage of arthroscopic shoulder surgery patients who underwent LHB tenodesis. (All patients who undergo biceps tenodesis also have, at the least, diagnostic shoulder arthroscopy with or without tenotomy; if the tendon is ruptured, tenotomy is unnecessary.)
Descriptive statistics were calculated as means (SDs) for continuous variables and as frequencies with percentages for categorical variables. Linear regression analysis was used to determine whether the number of LHB tenodesis procedures changed during the study period and whether patient age changed over time. Significance was set at P < .05.
Results
Of the 7640 patients who underwent arthroscopic shoulder procedures between 2004 and 2014, 2125 had LHB tenodesis (CPT code 23430).
Discussion
Tenodesis has become a common treatment option for several pathologic shoulder conditions involving the LHB tendon.5 We set out to determine trends in LHB tenodesis at a subspecialty-focused shoulder orthopedic practice and hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis. Our hypotheses were confirmed: The number of LHB tenodesis cases increased significantly without a significant change in patient age.
Treatment options for LHB pathology and SLAP tears include simple tenotomy, débridement, open biceps tenodesis, and arthroscopic tenodesis.11,12,15
Recent evidence has called into question the results of SLAP repairs and suggested biceps tenodesis may be a better treatment option for SLAP tears.10,13,21 Studies have found excellent outcomes with open subpectoral biceps tenodesis in the treatment of SLAP tears, and others have found better restoration of pitchers’ thoracic rotation with open subpectoral biceps tenodesis than with SLAP repair.13,14 Similarly, comparison studies have largely favored biceps tenodesis over SLAP repair, particularly in patients older than 35 years to 40 years.22 Given these results, it is not surprising that, querying the American Board of Orthopaedic Surgeons (ABOS) part II database for isolated SLAP lesions treated between 2002 and 2011, Patterson and colleagues23 found the percentage of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), whereas the percentage of biceps tenodesis procedures increased from 1.9% to 18.8% (P < .0001), indicating the realization of improved outcomes with LHB tenodesis in the treatment of SLAP tears. On the other hand, in the ABOS part II database for the period 2003 to 2008, Weber and colleagues24 found that, despite a decrease in the percentage of SLAP repairs, total number of SLAP repairs increased from 9.4% to 10.1% (P = .0163). According to our study results, the number of SLAP repairs is decreasing over time, whereas the number of LHB tenodesis procedures is continuing to rise. The practice patterns seen in our study correlate with those in previous studies of the treatment of SLAP tears: good results in tenodesis groups and poor results in SLAP repair groups.10,13Werner and colleagues25 recently used the large PearlDiver database, which includes information from both private payers and Medicare, to determine overall LHB tenodesis trends in the United States for the period 2008 to 2011. Over those years, the incidence of LHB tenodesis increased 1.7-fold, and the rate of arthroscopic LHB tenodesis increased significantly more than the rate of open LHB tenodesis. These results are similar to ours in that the number of LHB tenodesis cases increased significantly over time. However, as the overwhelming majority of patients in our practice undergo open biceps tenodesis, the faster rate of growth in the arthroscopic cohort relative to the open cohort cannot be assessed. Additional randomized studies comparing biceps tenodesis, both open and arthroscopic, with SLAP repair are needed to properly determine the superiority of LHB tenodesis over SLAP repair.
One strength of this database study was the number of patients: more than 7000, 2125 of whom underwent biceps tenodesis performed by 1 of 4 fellowship-trained orthopedic surgeons. There were several study limitations. First, because the original diagnoses were not recorded, it was unclear exactly which pathologies were treated with tenodesis, limiting our ability to make recommendations regarding treatment trends for specific pathologies. Similarly, we did not assess outcome variables, which would have allowed us to draw conclusions about the effectiveness of the biceps tenodesis procedures. Furthermore, some procedures may have been coded incorrectly, and therefore some patients may have been erroneously included or excluded. In addition, using data from only one institution may have introduced bias into our conclusions, though the results are consistent with national trends. Finally, there was some variability among the 4 surgeons in the number of LHB tenodesis procedures performed, and this variability may have confounded results, though these surgeons treat biceps pathology in similar ways.
Am J Orthop. 2017;46(4):E219-E223. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- The LHB tendon has been shown to be a significant pain generator in the shoulder.
- At our institution, the number of LHB tenodeses significantly increased from 2004 to 2014.
- The age of patients who underwent a LHB tenodesis did not change significantly over the study period.
- Furthermore, the percentage of shoulder procedures that involved a LHB tenodesis significantly increased over the study period.
- Biceps tenodesis has become a more common procedure to treat shoulder pathology.
Although the exact function of the long head of the biceps (LHB) tendon is not completely understood, it is accepted that the LHB tendon can be a significant source of pain within the shoulder.1-4 Patients with symptoms related to biceps pathology often present with anterior shoulder pain that worsens with flexion and supination of the affected elbow and wrist.5 Although the sensitivity and specificity of physical examination maneuvers have been called into question, special tests have been developed to aid in the diagnosis of tendonitis of the LHB. These tests include the Speed, Yergason, bear hug, and uppercut tests as well as the O’Brien test (cross-body adduction).6,7 Recent studies have found LHB pathology in 45% of patients who undergo rotator cuff repair and in 63% of patients with a subscapularis tear.8,9
Pathology of the LHB tendon, including superior labrum anterior to posterior (SLAP) tears, can be treated in many ways.5,10,11 Options include SLAP repair, biceps tenodesis, débridement, and biceps tenotomy.11,12 Results of SLAP repairs have been less than optimal, but biceps tenodesis has been effective, and avoids the issue of cramping as can be seen with biceps tenotomy and débridement.10,12,13 Surgical methods for biceps tenodesis include open subpectoral and all-arthroscopic.11,12 Both methods have had good, reliable outcomes, but the all-arthroscopic technique is relatively new.11,12,14We conducted a study to determine LHB tenodesis trends, including patient age at time of surgery. We used surgical data from fellowship-trained sports or shoulder/elbow orthopedic surgeons at a busy subspecialty-based shoulder orthopedic practice. We hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis.
Methods
Our Institutional Review Board exempted this study. To determine the number of LHB tenodesis procedures performed at our institution, overall and in comparison with other common arthroscopic shoulder procedures, we queried the surgical database of 4 fellowship-trained orthopedic surgeons (shoulder/elbow, Drs. Nicholson and Cole; sports, Drs. Romeo and Verma) for the period January 1, 2004 to December 31, 2014. We used Current Procedural Terminology (CPT) code 23430 to determine the number of LHB tenodesis cases, as the surgeons primarily perform an open subpectoral biceps tenodesis. Patient age at time of surgery and the date of surgery were recorded. All patients who underwent LHB tenodesis between January 1, 2004 and December 31, 2014 were included. Number of procedures performed each year by each surgeon was recorded, as were concomitant procedures performed at the same time as the LHB tenodesis. To get the denominator (and reference point) for the number of arthroscopic shoulder surgeries performed by these 4 surgeons during the study period, and thereby determine the rate of LHB tenodesis, we selected the most common shoulder arthroscopy CPT codes used in our practice: 23430, 29806, 29807, 29822, 29823, 29825, 29826, and 29827. For a patient who underwent multiple procedures on the same day (multiple CPT codes entered on the same day), only one code was counted for that day. If 23430 was among the codes, it was included, and the case was placed in the numerator; if 23430 was not among the codes, the case was placed in the denominator.
The Arthroscopy Association of North America provides descriptions for the CPT codes: 23430 (tenodesis of long tendon of biceps), 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy), 29807 (arthroscopy, shoulder, surgical; repair of SLAP lesion), 29822 (arthroscopy, shoulder, surgical; débridement, limited), 29823 (arthroscopy, shoulder, surgical; débridement, extensive), 29825 (arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation), 29826 (arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release), and 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair).
For analysis, we divided the data into total number of arthroscopic shoulder procedures performed by each surgeon each year and number of LHB tenodesis procedures performed by each surgeon each year. Total number of patients who had an arthroscopic procedure was used to create a denominator, and number of LHB tenodesis procedures showed the percentage of arthroscopic shoulder surgery patients who underwent LHB tenodesis. (All patients who undergo biceps tenodesis also have, at the least, diagnostic shoulder arthroscopy with or without tenotomy; if the tendon is ruptured, tenotomy is unnecessary.)
Descriptive statistics were calculated as means (SDs) for continuous variables and as frequencies with percentages for categorical variables. Linear regression analysis was used to determine whether the number of LHB tenodesis procedures changed during the study period and whether patient age changed over time. Significance was set at P < .05.
Results
Of the 7640 patients who underwent arthroscopic shoulder procedures between 2004 and 2014, 2125 had LHB tenodesis (CPT code 23430).
Discussion
Tenodesis has become a common treatment option for several pathologic shoulder conditions involving the LHB tendon.5 We set out to determine trends in LHB tenodesis at a subspecialty-focused shoulder orthopedic practice and hypothesized that the rate of LHB tenodesis would increase significantly over time and that there would be no significant change in the age of patients who underwent LHB tenodesis. Our hypotheses were confirmed: The number of LHB tenodesis cases increased significantly without a significant change in patient age.
Treatment options for LHB pathology and SLAP tears include simple tenotomy, débridement, open biceps tenodesis, and arthroscopic tenodesis.11,12,15
Recent evidence has called into question the results of SLAP repairs and suggested biceps tenodesis may be a better treatment option for SLAP tears.10,13,21 Studies have found excellent outcomes with open subpectoral biceps tenodesis in the treatment of SLAP tears, and others have found better restoration of pitchers’ thoracic rotation with open subpectoral biceps tenodesis than with SLAP repair.13,14 Similarly, comparison studies have largely favored biceps tenodesis over SLAP repair, particularly in patients older than 35 years to 40 years.22 Given these results, it is not surprising that, querying the American Board of Orthopaedic Surgeons (ABOS) part II database for isolated SLAP lesions treated between 2002 and 2011, Patterson and colleagues23 found the percentage of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), whereas the percentage of biceps tenodesis procedures increased from 1.9% to 18.8% (P < .0001), indicating the realization of improved outcomes with LHB tenodesis in the treatment of SLAP tears. On the other hand, in the ABOS part II database for the period 2003 to 2008, Weber and colleagues24 found that, despite a decrease in the percentage of SLAP repairs, total number of SLAP repairs increased from 9.4% to 10.1% (P = .0163). According to our study results, the number of SLAP repairs is decreasing over time, whereas the number of LHB tenodesis procedures is continuing to rise. The practice patterns seen in our study correlate with those in previous studies of the treatment of SLAP tears: good results in tenodesis groups and poor results in SLAP repair groups.10,13Werner and colleagues25 recently used the large PearlDiver database, which includes information from both private payers and Medicare, to determine overall LHB tenodesis trends in the United States for the period 2008 to 2011. Over those years, the incidence of LHB tenodesis increased 1.7-fold, and the rate of arthroscopic LHB tenodesis increased significantly more than the rate of open LHB tenodesis. These results are similar to ours in that the number of LHB tenodesis cases increased significantly over time. However, as the overwhelming majority of patients in our practice undergo open biceps tenodesis, the faster rate of growth in the arthroscopic cohort relative to the open cohort cannot be assessed. Additional randomized studies comparing biceps tenodesis, both open and arthroscopic, with SLAP repair are needed to properly determine the superiority of LHB tenodesis over SLAP repair.
One strength of this database study was the number of patients: more than 7000, 2125 of whom underwent biceps tenodesis performed by 1 of 4 fellowship-trained orthopedic surgeons. There were several study limitations. First, because the original diagnoses were not recorded, it was unclear exactly which pathologies were treated with tenodesis, limiting our ability to make recommendations regarding treatment trends for specific pathologies. Similarly, we did not assess outcome variables, which would have allowed us to draw conclusions about the effectiveness of the biceps tenodesis procedures. Furthermore, some procedures may have been coded incorrectly, and therefore some patients may have been erroneously included or excluded. In addition, using data from only one institution may have introduced bias into our conclusions, though the results are consistent with national trends. Finally, there was some variability among the 4 surgeons in the number of LHB tenodesis procedures performed, and this variability may have confounded results, though these surgeons treat biceps pathology in similar ways.
Am J Orthop. 2017;46(4):E219-E223. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: implications for restoring physiological length–tension relation during biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28(10):1352-1358.
2. Ejnisman B, Monteiro GC, Andreoli CV, de Castro Pochini A. Disorder of the long head of the biceps tendon. Br J Sports Med. 2010;44(5):347-354.
3. Mellano CR, Shin JJ, Yanke AB, Verma NN. Disorders of the long head of the biceps tendon. Instr Course Lect. 2015;64:567-576.
4. Szabo I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Med Arthrosc Rev. 2008;16(3):180-186.
5. Harwin SF, Birns ME, Mbabuike JJ, Porter DA, Galano GJ. Arthroscopic tenodesis of the long head of the biceps. Orthopedics. 2014;37(11):743-747.
6. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20(3):231-236.
7. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37(9):1840-1847.
8. Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23(1):73-80.
9. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy. 2008;24(12):1381-1389.
10. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013;41(4):880-886.
11. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Am J Sports Med. 2015;43(5):1077-1083.
12. Delle Rose G, Borroni M, Silvestro A, et al. The long head of biceps as a source of pain in active population: tenotomy or tenodesis? A comparison of 2 case series with isolated lesions. Musculoskelet Surg. 2012;96(suppl 1):S47-S52.
13. Chalmers PN, Trombley R, Cip J, et al. Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears. Am J Sports Med. 2014;42(12):2825-2836.
14. Gupta AK, Chalmers PN, Klosterman EL, et al. Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear. Orthopedics. 2015;38(1):e48-e53.
15. Ge H, Zhang Q, Sun Y, Li J, Sun L, Cheng B. Tenotomy or tenodesis for the long head of biceps lesions in shoulders: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0121286.
16. Kaback LA, Gowda AL, Paller D, Green A, Blaine T. Long head biceps tenodesis with a knotless cinch suture anchor: a biomechanical analysis. Arthroscopy. 2015;31(5):831-835.
17. Kany J, Guinand R, Amaravathi RS, Alassaf I. The keyhole technique for arthroscopic tenodesis of the long head of the biceps tendon. In vivo prospective study with a radio-opaque marker. Orthop Traumatol Surg Res. 2015;101(1):31-34.
18. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. 2008;36(10):1922-1929.
19. Provencher MT, LeClere LE, Romeo AA. Subpectoral biceps tenodesis. Sports Med Arthrosc Rev. 2008;16(3):170-176.
20. Erickson BJ, Jain A, Abrams GD, et al. SLAP lesions: trends in treatment. Arthroscopy. 2016;32(6):976-981.
21. Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med. 2015;43(5):1274-1282.
22. Denard PJ, Ladermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics. 2014;37(3):e292-e297.
23. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of Orthopaedic Surgery certification examination database. Am J Sports Med. 2014;42(8):1904-1910.
24. Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40(7):1538-1543.
25. Werner BC, Brockmeier SF, Gwathmey FW. Trends in long head biceps tenodesis. Am J Sports Med. 2015;43(3):570-578.
1. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: implications for restoring physiological length–tension relation during biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28(10):1352-1358.
2. Ejnisman B, Monteiro GC, Andreoli CV, de Castro Pochini A. Disorder of the long head of the biceps tendon. Br J Sports Med. 2010;44(5):347-354.
3. Mellano CR, Shin JJ, Yanke AB, Verma NN. Disorders of the long head of the biceps tendon. Instr Course Lect. 2015;64:567-576.
4. Szabo I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Med Arthrosc Rev. 2008;16(3):180-186.
5. Harwin SF, Birns ME, Mbabuike JJ, Porter DA, Galano GJ. Arthroscopic tenodesis of the long head of the biceps. Orthopedics. 2014;37(11):743-747.
6. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20(3):231-236.
7. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37(9):1840-1847.
8. Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23(1):73-80.
9. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy. 2008;24(12):1381-1389.
10. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013;41(4):880-886.
11. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Am J Sports Med. 2015;43(5):1077-1083.
12. Delle Rose G, Borroni M, Silvestro A, et al. The long head of biceps as a source of pain in active population: tenotomy or tenodesis? A comparison of 2 case series with isolated lesions. Musculoskelet Surg. 2012;96(suppl 1):S47-S52.
13. Chalmers PN, Trombley R, Cip J, et al. Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears. Am J Sports Med. 2014;42(12):2825-2836.
14. Gupta AK, Chalmers PN, Klosterman EL, et al. Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear. Orthopedics. 2015;38(1):e48-e53.
15. Ge H, Zhang Q, Sun Y, Li J, Sun L, Cheng B. Tenotomy or tenodesis for the long head of biceps lesions in shoulders: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0121286.
16. Kaback LA, Gowda AL, Paller D, Green A, Blaine T. Long head biceps tenodesis with a knotless cinch suture anchor: a biomechanical analysis. Arthroscopy. 2015;31(5):831-835.
17. Kany J, Guinand R, Amaravathi RS, Alassaf I. The keyhole technique for arthroscopic tenodesis of the long head of the biceps tendon. In vivo prospective study with a radio-opaque marker. Orthop Traumatol Surg Res. 2015;101(1):31-34.
18. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. 2008;36(10):1922-1929.
19. Provencher MT, LeClere LE, Romeo AA. Subpectoral biceps tenodesis. Sports Med Arthrosc Rev. 2008;16(3):170-176.
20. Erickson BJ, Jain A, Abrams GD, et al. SLAP lesions: trends in treatment. Arthroscopy. 2016;32(6):976-981.
21. Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med. 2015;43(5):1274-1282.
22. Denard PJ, Ladermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics. 2014;37(3):e292-e297.
23. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of Orthopaedic Surgery certification examination database. Am J Sports Med. 2014;42(8):1904-1910.
24. Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40(7):1538-1543.
25. Werner BC, Brockmeier SF, Gwathmey FW. Trends in long head biceps tenodesis. Am J Sports Med. 2015;43(3):570-578.
Rates of Deep Vein Thrombosis Occurring After Osteotomy About the Knee
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.