Journal of Shoulder and Elbow Surgery

Journal of Shoulder and Elbow Surgery

Impact of scapular notching on reverse total shoulder arthroplasty midterm outcomes: 5-year minimum follow-up

18-07-2019 – Ryan Simovitch, Pierre-Henri Flurin, Thomas W. Wright, Joseph D. Zuckerman, Christopher Roche

Journal Article

The impact of scapula notching on reverse total shoulder arthroplasty (r
TSA) clinical outcomes is controversial. The purpose of this study was to conduct a sufficiently statistically powered analysis to quantify the impact of scapular notching on midterm r
TSA outcomes. There were 324 r
TSA patients with 5 years of minimum follow-up evaluated. Patients were stratified according to the presence of a scapular notch at latest follow-up; radiographs were also assessed at each time point for patients with notching to determine the time for notch grade development. A 2-tailed, unpaired t-test compared preoperative, postoperative, and preoperative to postoperative outcomes between cohorts. There were 324 patients having an average follow-up of 75.1 months assessed; 47 (14.5%) patients had scapular notching. For scapular notching patients, the average notching grade was 1.7 ± 0.8 (24 grade 1, 15 grade 2, and 8 grade 3). The average time to notch development was 51.4 ± 24.1 months; grade 1, grade 2, and grade 3 notches developed at 49.0 ± 22.1 months, 57.5 ± 22.6 months, and 71.6 ± 15.8 months, respectively. No preoperative differences were observed between cohorts. At latest follow-up, scapular notching patients had significantly worse outcome scores and significantly less active abduction, forward flexion, and strength. Finally, scapular notching patients had significantly more complications, revisions, and humeral radiolucent lines. Scapular notching patients had significantly worse clinical outcomes and less range of motion than patients without scapular notching; these differences exceeded the minimal clinically important difference threshold for several outcome metrics. Based on these results, we recommend minimizing scapular notching through patient and implant selection and technique modification.

Axillary artery intimal dissection with thrombosis and brachial plexus injury after reverse total shoulder arthroplasty

23-10-2019 – Jacob Wilkerson, Matthew Napierala, Sherene Shalhub, Winston J. Warme

Journal Article

Anatomic shoulder parameters and their relationship to the presence of degenerative rotator cuff tears and glenohumeral osteoarthritis: a systematic review and meta-analysis

30-07-2019 – Musa B. Zaid, Nathan M. Young, Valentina Pedoia, Brian T. Feeley, C. Benjamin Ma, Drew A. Lansdown

Journal Article, Review

Scapular anatomy, as measured by the acromial index (AI), critical shoulder angle (CSA), lateral acromial angle (LAA), and glenoid inclination (GI), has emerged as a possible contributor to the development of degenerative shoulder conditions such as rotator cuff tears and glenohumeral osteoarthritis. The purpose of this study was to investigate the published literature on influences of scapular morphology on the development of degenerative shoulder conditions. A systematic review of the Embase and PubMed databases was performed to identify published studies on the potential influence of scapular bony morphology on the development of degenerative rotator cuff tears and glenohumeral osteoarthritis. The studies were reviewed by 2 authors. The findings were summarized for various anatomic parameters. A meta-analysis was completed for parameters reported in more than 5 related publications. A total of 660 unique titles and 55 potentially relevant abstracts were reviewed with 30 published articles identified for inclusion. The AI, CSA, LAA, and GI were the most commonly reported bony measurements. Increased CSA and AI correlated with rotator cuff tears, whereas lower CSA appeared to be related to the presence of glenohumeral osteoarthritis. Decreased LAA correlated with degenerative rotator cuff tears. Five articles reported on the GI with mixed results on shoulder pathology. Degenerative rotator cuff tears appear to be significantly associated with the AI, CSA, and LAA. There does not appear to be a significant relationship between the included shoulder parameters and the development of osteoarthritis.

Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review

14-08-2019 – Ryan A. Paul, Naomi Maldonado-Rodriguez, Shgufta Docter, Moin Khan, Christian Veillette, Nikhil Verma, Gregory Nicholson, Timothy Leroux

Journal Article, Review

Reverse total shoulder arthroplasty (RSA) with glenoid bone grafting has become a common option for management of glenoid bone loss associated with glenohumeral osteoarthritis. The objectives of this review were to determine (1) the rate of graft union, (2) the revision and complication rates, and (3) functional outcomes following primary RSA with glenoid bone grafting. A comprehensive search of the MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was completed for studies reporting clinical outcomes following primary RSA with glenoid bone grafting. Pooled and frequency-weighted means were calculated where applicable. Overall, 11 studies and 393 patients were included in the study. The mean patient age was 73 ± 2.2 years, and the mean follow-up period was 34 ± 10 months. The overall graft union rate was 95%, but the rate was 97% among cases using autograft bone (8 studies, n = 254). When stratified by technique, concentric bone grafts had a 100% union rate (4 studies, n = 139). Conversely, eccentric grafts had an overall union rate of 92% (7 studies, n = 240), which improved to 94% when using autograft bone (4 studies, n = 115). At final follow-up, the revision rate was 2%, the complication rate was 18%, and there was consistent improvement in range of motion and functional outcome scores. Glenoid bone grafting during primary RSA results in excellent early-term clinical outcomes, low complication and revision rates, and high rates of graft union.

Effect of different trunk postures on scapular muscle activities and kinematics during shoulder external rotation

15-08-2019 – Kosuke Miyakoshi, Jun Umehara, Tomohito Komamura, Yasuyuki Ueda, Toru Tamezawa, Gakuto Kitamura, Noriaki Ichihashi

Journal Article

Shoulder external rotation at abduction (ER) is a notable motion in overhead sports because it could cause strong stress to the elbow and shoulder joint. However, no study has comprehensively investigated the effect of different trunk postures during ER. This study aimed to investigate the effect of different trunk postures on scapular kinematics and muscle activities during ER. Fourteen healthy men performed active shoulder external rotation at 90° of abduction with the dominant arm in 15 trunk postures. At maximum shoulder external rotation in 15 trunk postures, including 4 flexion-extension, 6 trunk rotation, and 4 trunk side-bending postures, as well as upright posture as a control, scapular muscle activities and kinematics were recorded using surface electromyography and an electromagnetic tracking device, respectively. The data obtained in the flexion-extension, trunk rotation, and trunk side-bending postures were compared with those obtained in the upright posture. In the flexion-extension condition, scapular posterior tilt and external rotation significantly decreased, but the muscle activities of the lower trapezius and infraspinatus significantly increased in maximum trunk flexion. Moreover, scapular upward rotation and the activity of the serratus anterior significantly increased in maximum trunk extension. In the rotation condition, scapular posterior tilt and external rotation significantly decreased, but the activity of the serratus anterior significantly increased in the maximum contralateral trunk rotation posture. In the trunk side-bending condition, scapular posterior tilt and the external rotation angle significantly decreased. Trunk postures affected scapular kinematics and muscle activities during ER. Our results suggest that different trunk postures activate the lower trapezius and serratus anterior, which induce scapular posterior tilt.

Biomechanical analysis of conventional anchor revision after all-suture anchor pullout: a human cadaveric shoulder model

18-07-2019 – Dimitris Ntalos, Gerd Huber, Kay Sellenschloh, Daniel Briem, Klaus Püschel, Michael M. Morlock, Karl-Heinz Frosch, Darius M. Thiesen, Till O. Klatte

Journal Article

The possibility of implanting a conventional anchor at the pullout site following all-suture anchor failure was evaluated in a biomechanical cadaveric model. The hypothesis of the study was that anchor revision would yield equal biomechanical properties. Ten human humeri were obtained, and bone density was determined via computed tomography. After all-suture anchor (n = 5) and conventional 4.5-mm anchor (n = 5) insertion, biomechanical testing was conducted. Following all-suture anchor pullout, a conventional 5.5-mm anchor was inserted at the exact site of pullout (n = 5) and biomechanical testing was reinitiated. Testing was conducted using an initial preload of 20 N, followed by an unlimited cyclic protocol, with a stepwise increasing force of 0.05 N for each cycle at a rate of 1 Hz until system failure. The number of cycles, maximum load to failure, stiffness, displacement, and failure mode, as well as macroscopic observation at the failure site including diameter, shape, and cortical destruction, were registered. The defect following all-suture pullout showed a mean diameter of 4 mm, and conventional revision was possible in each sample. There was no significant difference between the initial all-suture anchor implantation and the conventional anchor implantation or the conventional revision following all-suture failure regarding mean pullout strength, stiffness, displacement, or total number of cycles until failure. Conventional anchor revision at the exact same site where all-suture anchor pullout occurred is possible and exhibits similar biomechanical properties.

PROMIS CAT forms demonstrate responsiveness in patients following arthroscopic rotator cuff repair across numerous health domains

20-08-2019 – Felicity Fisk, Sreten Franovic, Joseph S. Tramer, Caleb Gulledge, Noah A. Kuhlmann, Chaoyang Chen, Vasilios Moutzouros, Stephanie Muh, Eric C. Makhni

Journal Article

Recent studies of patients with rotator cuff tears have demonstrated improved efficiency with Patient-Reported Outcomes Measurement Information System (PROMIS) when compared with traditional patient-reported outcome measures (PROM). However, these studies have been cross-sectional in nature and the responsiveness of PROMIS computer adaptive test (CAT) forms has not been evaluated. The purpose of this study was to determine the responsiveness of PROMIS CAT assessments in patients undergoing arthroscopic rotator cuff repair. All patients undergoing arthroscopic rotator cuff repair by one of 3 fellowship-trained surgeons were included in the study. PROMIS CAT upper extremity physical function (“PROMIS-UE”), pain interference (“PROMIS-PI”), and depression (“PROMIS-D”) scores from preoperative and 6-month postoperative visits were collected and analyzed. Patient-centric demographic factors, tear size, and biceps involvement were also correlated to preoperative and postoperative PROMIS scores. A total of 101 patients were enrolled in the study. The average age was 59.8 ± 8.9 years with 51 males (50.5%). Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D CAT scores improved significantly from 29.8 ± 6.0, 62.6 ± 5.1, and 48.4 ± 8.7, respectively, to 40.9 ± 9.8, 51.2 ± 9.3, and 42.9 ± 9.0, respectively, at 6-month follow-up (P < .001). Preoperative correlations were found between PROMIS-UE and PROMIS-PI scores (P < .001) and between PROMIS-PI and PROMIS-D scores (P = .001). No significant correlation was found between PROMIS-UE and PROMIS-D scores (P = .08), preoperatively. Preoperative PROMIS-UE, PROMIS-PI, or PROMIS-D scores were not correlated with rotator cuff tear size (P = .4). PROMIS CAT forms demonstrate responsiveness in patients undergoing arthroscopic rotator cuff repair across numerous domains.

Bone defect–induced alteration in glenoid articular surface geometry and restoration with coracoid transfer procedures: a cadaveric study

22-07-2019 – Deepak N. Bhatia, Vikram Kandhari

Journal Article

This study analyzed the alteration in glenoid articular geometry with increasing anterior bone loss, as well as its subsequent correction with 2 modifications of the Latarjet procedure. Anterior defects were simulated by creating glenoid osteotomies (10%, 20%, 30%, and 40%), and defects were reconstructed using 2 Latarjet modifications (classic and congruent arc). A total of 108 computed tomography scans were performed (1) on intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). Glenoid parameters (width, area, arc length, and version) were analyzed on computed tomography scans. Statistical analysis was used to determine significant differences between intact, deficient, and reconstructed glenoids. All parameters were reduced with every 10% defect increment (mean change in width, 2.5 mm; area, 64 mm Glenoid articular geometry is progressively altered with a sequential increase in anterior bone defects from 0% to 40%. The classic Latarjet procedure provided significant correction in bone defects of 10% and 20%. The congruent-arc Latarjet procedure restored and overcorrected most parameters even in 40% glenoid defects.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery

20-08-2019 – Joseph J. Ruzbarsky, Ryan C. Rauck, Joseph Manzi, Sariah Khormaee, Bridget Jivanelli, Russell F. Warren

Journal Article

Considered the gold standard of study designs, randomized controlled trials’ (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery. A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold. Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis. The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Validation of the registration accuracy of navigation-assisted arthroscopic débridement for elbow osteoarthritis

26-08-2019 – Atsuo Shigi, Kunihiro Oka, Hiroyuki Tanaka, Shingo Abe, Satoshi Miyamura, Masaki Takao, Tatsuo Mae, Hideki Yoshikawa, Tsuyoshi Murase

Journal Article

The identification and precise removal of bony impingement lesions during arthroscopic débridement arthroplasty for elbow osteoarthritis is technically difficult. Surgical navigation systems, combined with preoperative 3-dimensional (3D) assessment of bony impingements, can provide real-time tracking of the surgical instruments and impingement lesions. This study aims to determine the registration accuracy of the navigation system for the humerus and ulna during elbow arthroscopy. We tested the registration procedure using resin bone models of 3 actual patients with elbow osteoarthritis. We digitized bone surface points using navigation pointers under arthroscopy. We initially performed paired-point registration, digitizing 6 preset anatomical landmarks, and then refined the initial alignment with surface matching registration, digitizing 30 points. The registration accuracy for each trial was evaluated as the mean target registration error in each reference marker. Three observers repeated the registration procedure 5 times each with the 3 specimens (total, 45 trials). The median of the registration accuracy was evaluated in total (45 trials) as the accuracy of the registration procedure. The differences in the registration accuracy among the 3 observers (median of 15 trials) were also examined. The total registration accuracies were 0.96 mm for the humerus and 0.85 mm for the ulna. No significant differences were found in the registration accuracy for the humerus and ulna among the 3 observers. This arthroscopic-assisted registration procedure is sufficiently feasible and accurate for application of the navigation system to arthroscopic débridement arthroplasty in clinical settings.

The effect of stem fit on the radiocapitellar contact mechanics of a metallic axisymmetric radial head hemiarthroplasty: is loose fit better than rigidly fixed?

03-08-2019 – Jakub Szmit, Graham J.W. King, James A. Johnson, G. Daniel G. Langohr

Journal Article

Radial head hemiarthroplasty is commonly used to manage comminuted displaced fractures. Regarding implant fixation, current designs vary, with some prostheses aiming to achieve a tight “fixed” fit and others using a smooth stem with an over-reamed “loose” fit. The purpose of this study was to evaluate the effect of radial head hemiarthroplasty stem fit on radiocapitellar contact using a finite element model that simulated both fixed (size-for-size) and loose (1-, 2-, and 3-mm over-reamed) stem fits. It was hypothesized that a loose stem fit would improve radiocapitellar contact mechanics, with an increased contact area and decreased contact stress, by allowing the implant to find its “optimal” position with respect to the capitellum. Finite element models of the elbow were produced to compare the effects of stem fit on radiocapitellar contact of a metallic axisymmetric radial head implant. Radiocapitellar contact mechanics (contact area and maximum contact stress) were computed for 0°, 45°, 90°, and 135° of elbow flexion with the forearm in neutral rotation, pronation, and supination. The data suggest that the loose smooth stem radial head implant may be functioning like a bipolar implant in optimizing radiocapitellar contact. Over-reaming of 3 mm produced a larger amount of stress concentration on the capitellum, suggesting there may be a limit to how loose a smooth stem implant should be implanted. The loose 1 to 2 mm over-reamed stem provided optimal contact mechanics of the metallic axisymmetric radial head implant compared with the fixed stem.

Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review

01-09-2019 – Daniel Stover, Benjamin Fick, Ruth L. Chimenti, Mederic M. Hall

Journal Article

Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up. Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation [SD], 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up. Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate. Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy.

Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification

24-11-2019 – Fengfeng Li, Dong Mao, Xiaoyun Pan, Xin Zhang, Jingyi Mi, Yongjun Rui

Journal Article

Heterotopic ossification (HO) is a recognized sequela after trauma and arthroplasty. The purpose of this study was to evaluate the therapeutic effect of celecoxib on HO. We hypothesized that celecoxib may inhibit the progression of initiated HO. We performed a retrospective review of 37 patients who underwent elbow joint surgery between January 2014 and June 2018. Seventeen patients were prescribed orally administered celecoxib (200 mg/dose, twice daily) for 2 months after the diagnosis of HO, whereas the remaining 20 patients were administered celecoxib for 1 month starting immediately after surgery. HO progression was evaluated by plain radiographs. By use of an Achilles tendon puncture-induced HO mouse model, the curative effect of celecoxib was illustrated at different HO progression stages. The mice were assigned to 1 of 4 groups: sham group, vehicle group, group receiving celecoxib on day 1, and group receiving celecoxib in week 6. Achilles tendons were analyzed by micro-computed tomography and histochemistry after 12 weeks. Celecoxib did not inhibit the progression of initiated HO in the patients in whom HO was diagnosed, whereas those who received celecoxib after surgery had lower morbidity. Achilles tendon puncture effectively induced typical HO in mice. The ectopic bone volume was significantly reduced in the day 1 celecoxib group compared with the vehicle group; however, the difference was not statistically significant in the week 6 celecoxib group. Administration of celecoxib starting immediately after surgery can significantly inhibit the formation of HO. Once HO is visible on plain radiographs or micro-computed tomography, celecoxib cannot effectively attenuate further progression of HO in humans and mice.

Supination torque following single- versus double-incision repair of acute distal biceps tendon ruptures

18-10-2019 – David J. Stockton, Gabriel Tobias, Jeffrey M. Pike, Parham Daneshvar, Thomas J. Goetz

Journal Article

Compared with single-incision (SI) distal biceps repair, double-incision (DI) repair has been described as permitting a more anatomic repair. We hypothesized that DI repair would result in greater terminal supination torque compared with SI repair for acute distal biceps ruptures. Patients were included if they sustained an isolated, acute distal biceps rupture repaired between January 2012 and December 2017. Isometric forearm supination torque in 4 positions was measured using a validated uniaxial torque-testing device. Testing took place at least 12 months from surgery. The primary outcome was supination torque in the 60° supinated position. Secondary outcomes included supination torque in other forearm positions and functional outcome scores. The study included 37 patients: 15 underwent repair with the DI technique and 22 with the SI technique. The mean age was 47.3 years, the median follow-up time was 28.1 months, and demographic data were similar between cohorts. Mean supination torque, relative to the unaffected side, was 61% (95% confidence interval, 45%-77%) for DI repair vs. 80% (95% confidence interval, 69%-92%) for SI repair in the 60° supinated position (P = .036). In a multivariable linear regression model controlling for arm dominance, age, follow-up time, and workers’ compensation status; SI repair was associated with greater mean supination torque than DI repair by 20% (P = .015). Contrary to our hypothesis, we found a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the SI technique compared with the DI technique. This finding may have clinical significance for the more discerning, high-demand patient.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle

03-08-2019 – Tony Chieh-Ting Huang, M. Diya Sabbagh, Chun-Kuan Lu, Scott P. Steinmann, Steven L. Moran

Journal Article

Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion. A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients’ demographics, time to union, and postoperative complications were collected. A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal. The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.

Functional improvements in active elevation, external rotation, and internal rotation after reverse total shoulder arthroplasty with isolated latissimus dorsi transfer: surgical technique and midterm follow-up

14-07-2019 – Ion-Andrei Popescu, Thomas Bihel, Daniel Henderson, Javier Martin Becerra, Jens Agneskirchner, Laurent Lafosse

Journal Article

This study investigated the hypothesis that reverse total shoulder arthroplasty (RSA) in combination with an isolated latissimus dorsi tendon (LDT) transfer in patients with pseudoparalysis of abduction and external rotation (combined loss of active elevation and external rotation [CLEER] syndrome) would demonstrate improved postoperative functional results. This study was a retrospective single-surgeon case series of 13 consecutive patients with CLEER who underwent RSA without subscapularis repair and combined with an isolated LDT transfer. We reviewed 10 patients (77%), at a minimum of 2 years, with 3 cases lost to follow-up. Shoulder function was assessed preoperatively and postoperatively using the Constant score and postoperatively using the Oxford Shoulder Score, University of California-Los Angeles score, American Shoulder and Elbow Surgeons score, ADLEIR (activities of daily living [ADLs] requiring active external and internal rotation) score, and ADLIR (ADLs requiring active internal rotation) score. Force in internal rotation (IR) at 0° of abduction, external rotation (ER) at 0° of abduction, and ER at 90° of abduction, as well as IR in the belly-press position, was measured. The mean postoperative follow-up period was 57 months (range, 31-85 months). We observed improvement in the Constant score (from 29.8 ± 6.64 preoperatively to 71.9 ± 10.45 postoperatively, P < .05), as well as abduction force, ER, and forward elevation (P < .05). Postoperatively, the mean American Shoulder and Elbow Surgeons score was 95.1 ± 3.38 and the mean Oxford Shoulder Score was 46.6 ± 1.57. Mean force in IR at 0° of abduction was 5.45 ± 2.42 kg, and mean force in ER at 90° of abduction was 4 ± 1.20 kg. Mean force in ER at 0° of abduction (3.65 ± 1.24 kg) and IR in the belly-press position (4.5 ± 2.84 kg) demonstrated a positive correlation with ADLs. The results of this study demonstrate that RSA without subscapularis repair, combined with an isolated LDT transfer, provides improved postoperative functional outcomes for patients with CLEER while maintaining sufficiently balanced force in IR and ER to effectively perform ADLs.

Evolution of nonoperative treatment of atraumatic sternoclavicular dislocation

28-07-2019 – Robin Moreels, Lieven De Wilde, Alexander Van Tongel

Journal Article

Atraumatic sternoclavicular dislocation (ASCD) is an uncommon pathology that is mainly diagnosed in young adults. The aim of this study is to better describe the clinical picture of ASCD and to describe the results of a “wait-and-see” policy in these patients. All patients with ASCD who visited our department between 2011 and 2016 were retrospectively analyzed. A standardized clinical examination was used to evaluate the clinical picture. All patients were treated nonoperatively, and at latest follow-up, several parameters and standardized questionnaires (Nottingham Clavicle Score, Oxford Shoulder Score, Constant-Murley Score) were used to evaluate the outcome. In total, 23 patients (12 male, 11 female) were evaluated. The average age at diagnosis was 18.6 years. There was a significant difference (P < .001) in angle of dislocation during forward flexion (mean = 141°) compared with abduction (mean = 101°). At latest follow-up (average 46 months, range 14-113 months; standard deviation [SD] = 27), subluxations still occurred but were less frequent and less prominent relative to presentation at initial diagnosis in 19 of 23 patients. The chance of subjective improvement increased by 27% for each year of follow-up. High outcome scores of Nottingham Clavicle Score (mean score = 80, SD = 11), Oxford Shoulder Score (mean score = 44, SD = 4), and Constant-Murley Score (mean score = 83, SD = 11) were reported. In patients with ASCD, the clavicle subluxates earlier in abduction than in forward flexion. After a midterm follow-up, a "wait-and-see" policy does not resolve the subluxations. However, most patients displayed reduced frequency and severity of subluxations over their recovery period and showed excellent scores on shoulder questionnaires.

Operative management of clavicular malunion in midshaft clavicular fractures: a report of 59 cases

29-07-2019 – David H. Strong, Michael W. Strong, Deborah Hermans, David Duckworth

Journal Article

Nonoperative management has long been the preferred treatment for clavicular fractures; however, good outcomes, particularly with a shortened and malunited clavicle, are not universal. We report on radiographic and patient-based outcomes of a patient cohort with symptomatic clavicular malunions managed with corrective osteotomy, plate fixation, and local bone graft. We hypothesized that local bone graft would be sufficient for achieving union and length of malunion time would not affect the outcome. Over a 10-year period, 59 cases underwent operative management of symptomatic clavicular malunion. The surgical technique included osteotomy of the malunion, restoration of length, fixation with a plate, and local bone graft. The average length of time between fracture and surgery was 193.42 weeks (range, 8 weeks to 30 years). All patients were followed up postoperatively until radiographic union was achieved. Disabilities of the Arm, Shoulder and Hand scores were obtained and patients completed questionnaires to assess patient-based outcomes postoperatively. All 59 cases achieved union with an average time of 9.25 weeks (range, 6-38 weeks) and only required local bone graft. All patients improved postoperatively with a mean Disabilities of the Arm, Shoulder and Hand score of 1.81 (range, 0-20.68) at 12 months. In 2 patients, infection developed, requiring revision of fixation, and union was subsequently achieved. Two patients had fractures adjacent to their hardware after union was achieved. Corrective osteotomy with restoration of length and alignment, soft-tissue preservation, local bone graft, and plate fixation is a reliable treatment option for midshaft clavicular malunion. Union can be achieved, with good clinical outcomes independent of malunion time.

Rapidly destructive arthropathy of shoulder joint

14-07-2019 – Myung Seo Kim, Jung Youn Kim, Jong Dae Kim, Kyung Han Ro, Yong Girl Rhee

Journal Article

Rapidly destructive arthropathy (RDA) of the shoulder is rare. Consequently, there are very few studies that have reported the characteristic findings of this disease. This study aimed to analyze the clinical, radiographic, and histologic features of patients with RDA of the shoulder. In total, 9 cases (8 patients) were enrolled in this study. All patients were elderly women, with a mean age of 72.7 years (range, 57-78 years). The mean duration of symptoms was 4.1 months (range, 1.2-5.9 months). Reverse total shoulder arthroplasty and total shoulder arthroplasty were performed in 5 cases with massive rotator cuff tears and 4 without them, respectively. The mean duration of radiologically evident joint destruction after negative results on radiography was 3.1 months (range, 1.0-5.9 months). On plain radiography, humeral head flattening and collapse that appeared like cut grass were observed (100%). Relatively good preservation of the glenoid with a normal joint space was observed in 7 cases, whereas glenoid erosion was observed in 2 (22.2%). T1-weighted magnetic resonance imaging showed a subchondral fracture (100%) of low signal intensity with associated bone marrow edema. Histologically, chronic inflammation of the synovium and osteocytes in the lacunae, as well as callus formation, were observed along the subchondral fracture. Flattening and collapse of the humeral head within an average of 4 months of symptom onset are characteristic of RDA of the shoulder. Bone marrow edema, joint effusion, and subchondral fracture on magnetic resonance imaging and fracture fragments and callus formation on histopathologic analysis were observed. Glenoid erosion was observed in 2 cases with arthrosis progression.

Performance and return to sport following rotator cuff surgery in professional baseball players

18-07-2019 – Brandon J. Erickson, Peter N. Chalmers, John DAngelo, Kevin Ma, Anthony A. Romeo

Journal Article

While many injuries to the rotator cuff in professional baseball players can be managed nonoperatively, recovery fails to occur with nonoperative treatment in some players and surgery on the rotator cuff is performed in an attempt to return to sport (RTS). All professional baseball players who underwent rotator cuff surgery between 2010 and 2016 were included by use of the Major League Baseball injury database. Demographic and performance data (before and after surgery) for each player were recorded. Preoperative and postoperative performance metrics were then compared. Overall, 151 professional baseball players underwent rotator cuff débridement (n = 130) or rotator cuff repair (n = 21). In the rotator cuff repair group, 6 (28.6%) underwent single-row repair, 5 (23.8%) underwent double-row repair, and 10 (47.6%) underwent side-to-side repair. Among the 11 players who underwent either single- or double-row repair, the average number of anchors used per repair was 2.09 ± 1.1 (range, 1-4). Most performance metrics declined following rotator cuff débridement. For players who underwent débridement, the RTS rate was 50.8% (42.3% at the same level or a higher level and 8.5% at a lower level). For players who underwent repair, the RTS rate was 33.3% (14.3% at the same level or a higher level and 19% at a lower level). Most players underwent at least 1 concomitant procedure at the time of rotator cuff surgery. Rotator cuff débridement is significantly more common than repair in professional baseball players, with 86% of all rotator cuff surgical procedures reported as débridement. RTS rates following débridement and repair are disappointing, at 50.8% and 33.3%, respectively. For players who do return, performance declines after surgery.

Treatment of acute shoulder infection: can osseous lesion be a rudder in guideline for determining the method of débridement?

05-08-2019 – Dong Ki Lee, Sung-Min Rhee, Ho Yeon Jeong, Kyunghan Ro, Yoon Sang Jeon, Yong Girl Rhee

Journal Article

There is no standard to determine the most appropriate method of operation for the treatment of acute septic arthritis of the shoulder joint. We retrospectively reviewed 57 patients who underwent arthroscopic or open débridement for acute shoulder infection between 2001 and 2015. Arthroscopic débridement was performed in 27 patients, and open débridement in 30 patients. According to the presence of bone erosion and/or marginal erosion of cartilage of the humeral head on plain radiographs and magnetic resonance imaging (MRI) images, the cases were classified into 3 groups (group 1, n = 23, without erosions in x-ray and MRI; group 2, n = 21, erosions seen in MRI but not in x-ray; and group 3, n = 13, with erosions seen in both x-ray and MRI). The arthroscopic group had a reinfection rate of 55.6% (15/27), and the open group had a reinfection rate of 16.7% (5/30). The reinfection rates in the arthroscopic and the open groups were 10% (1/10) and 15.4% (2/13) in group 1; 75% (9/12) and 11.1% (1/9) in group 2; and 100% (5/5) and 25% (2/8) in group 3, respectively. At the last follow-up, the mean University of California at Los Angeles score and the average time until normalization of white blood cell, erythrocyte sedimentation rate, and C-reactive protein in the open group showed superior results in the open group (all P < .05). When preoperative MRI showed bone and/or cartilage erosion of humeral head, the reinfection rate after arthroscopic débridement was above 75%. Therefore, if preoperative MRI showed erosions, open débridement is more likely to be appropriate than arthroscopic débridement.

Clinical and radiographic comparison of a hybrid cage glenoid to a cemented polyethylene glenoid in anatomic total shoulder arthroplasty

22-07-2019 – Richard J. Friedman, Emilie Cheung, Sean G. Grey, Pierre-Henri Flurin, Thomas W. Wright, Joseph D. Zuckerman, Christopher P. Roche

Journal Article

This study reports the clinical and radiographic outcomes of a hybrid cage glenoid compared with an age-matched, sex-matched, and follow-up-matched cohort of cemented all-polyethylene peg glenoids in patients undergoing anatomic total shoulder arthroplasty with 2 years’ minimum follow-up. We reviewed 632 primary anatomic total shoulder arthroplasty patients from an international multi-institutional database; 316 patients received hybrid cage glenoids and were matched for age, sex, and follow-up with 316 patients with cemented all-polyethylene peg glenoids. Each cohort received the same humeral component. Scoring was performed in all patients preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range-of-motion measurements. A Student 2-tailed unpaired t test identified differences in outcomes; P < .05 denoted a significant difference. Cage glenoid patients had significantly lower rates of radiolucent glenoid lines (9.0% vs. 37.6%, P < .0001) and radiolucent humeral lines (3.0% vs. 9.1%, P = .0088) than all-polyethylene peg glenoid patients. In the cage glenoid cohort, 4 cases of aseptic glenoid loosening (1.3%) and 4 cases of articular surface dissociation (1.3%) occurred. In the all-polyethylene peg cohort, 12 cases of aseptic loosening (3.8%) occurred. Cage glenoid patients had a significantly lower revision rate than all-polyethylene peg glenoid patients (2.5% vs. 6.9%, P = .0088). At 50 months' mean follow-up, cage glenoids demonstrated equally good clinical outcomes to all-polyethylene peg glenoids. Cage glenoids had significantly fewer radiolucent lines around both the glenoid and humeral components and a lower revision rate. Longer-term follow-up is required to confirm these promising short-term results.

Computer navigation re-creates planned glenoid placement and reduces correction variability in total shoulder arthroplasty: an in vivo case-control study

30-07-2019 – Piyush S. Nashikkar, Corey J. Scholes, Mark D. Haber

Journal Article

Accurate glenoid component placement is important to prevent glenoid component failure in total shoulder arthroplasty (TSA). Navigation may reduce the variability of glenoid component version and inclination; therefore, the aims of this study were to determine, in patients undergoing TSA, whether computer navigation improved the ability to achieve neutral postoperative version and inclination, as well as achieve the individualized preoperative plan. Patients undergoing TSA using navigation (computer-assisted surgery [CAS], n = 33) or the conventional technique (n = 27) from January 2014 to July 2017 were recruited and compared. Preoperative and postoperative version and inclination, as well as postoperative inferior overhang, were measured using computed tomography scans. The CAS group had more than twice as many augmented glenoid components as the conventional group (45.5% vs. 19.2%). CAS significantly reduced the between-patient variability in postoperative version and led to a greater proportion of components positioned in “neutral” alignment for both inclination and version (P < .015). The incidence of neutral inclination or version postoperatively was significantly higher in the CAS group, and the glenoid was implanted within 5° of the surgical plan in more than 70% of cases, with more than 40% displaying no detectable difference. An integrated system of 3-dimensional surgical planning, augmented glenoid components, and intraoperative navigation may reduce the risk of glenoid placement outside of a neutral position in patients undergoing TSA compared with conventional methods. This study demonstrated the capacity for CAS to replicate the surgical plan in a majority of cases.

“Prearthroplasty glenohumeral pathoanatomy and its relationship to patients sex, age, diagnosis, and self-assessed shoulder comfort and function”

18-07-2019 – Frederick A. Matsen, Anastasia Whitson, Jason E. Hsu, Nicole K. Stankovic, Moni B. Neradilek, Jeremy S. Somerson

Journal Article

There is great current interest in characterizing the prearthroplasty glenohumeral pathoanatomy because of its role in guiding surgical technique and its possible effects on arthroplasty outcome. We examined 544 patients within 6 weeks before arthroplasty with the goals of characterizing the following: demographic and radiographic characteristics; relationships of the radiographic pathoanatomy to the patient’s age, sex, and diagnosis; inter-relationships among glenoid type, glenoid version, and amount of decentering of the humeral head on the glenoid; and relationships of the pathoanatomy to the patient’s self-assessed comfort and function. Male patients had a higher frequency of B2 glenoids and a lower frequency of A2 glenoids. The arthritic shoulders of men were more retroverted and had greater amounts of posterior decentering. Patients with types A1 and C glenoids were younger than those with other glenoid types. Shoulders with osteoarthritis were more likely to be type B2 and to be retroverted. Types B2 and C had the greatest degree of retroversion, whereas types B1 and B2 had the greatest amounts of posterior decentering. Shoulders with glenoid types B1 and B2 and those with more decentering did not have worse self-assessed shoulder comfort and function. Glenohumeral pathoanatomy was found to have previously unreported relationships to the patient’s sex, age, and diagnosis. Contrary to what might have been expected, more advanced glenohumeral pathoanatomy (ie, type B glenoids, greater retroversion, greater decentering) was not associated with worse self-assessed shoulder comfort and function.

Intersection of catastrophizing, gender, and disease severity in preoperative rotator cuff surgical patients: a cross-sectional study

03-08-2019 – Eric Gibson, Justin LeBlanc, Marlis T. Sabo

Journal Article

Surgical outcomes are dependent on multiple clinical and patient factors. One patient factor is pain catastrophizing, which is associated with poorer outcomes in other surgical populations. Our purpose was to examine relationships between gender, patient-reported disease severity, and catastrophizing in patients in whom rotator cuff surgery is planned. We hypothesized that patients with more catastrophizing would report greater disease severity. Patients undergoing surgery for unilateral symptomatic rotator cuff disease aged 35 to 75 years were prospectively evaluated. Data collected included demographic characteristics; imaging characteristics; range of motion; and Western Ontario Rotator Cuff Index (WORC), Pain Catastrophizing Scale (PCS), and Short Form 36 scores. A total of 156 patients (87 men and 69 women) aged 54 ± 8 years participated. The mean WORC score was similar between men and women (1286 ± 343 vs. 1327 ± 370, P = .38). The mean PCS score was 14.7 ± 10.6 for men and 17.9 ± 12.4 for women (P = .08). A moderate positive correlation was found between the WORC and PCS scores (r = 0.59, P < .001). Women had poorer WORC-Lifestyle subscale scores (P = .012). Range of motion, Short Form 36 scores, and tear severity were not related to measures of either the WORC or PCS. The direct relationship between the WORC and PCS scores is consistent with research in other patient populations. Contrary to other work, no gender-based PCS score differences were observed. Differences on the WORC-Lifestyle subscale suggest that women may experience greater functional impacts to specific lifestyle elements than men. Catastrophizing is related to patient-reported disease severity in preoperative rotator cuff patients. Further research will clarify whether this relationship leads to poorer outcomes following surgery.

Cutibacterium acnes persists despite topical clindamycin and benzoyl peroxide

01-09-2019 – Nathanael Heckmann, K. Soraya Heidari, Omid Jalali, Alexander E. Weber, Rosemary She, Reza Omid, C. Thomas Vangsness, George F. “Rick” Hatch

Journal Article

Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The Mc
Nemar test was used to compare the proportion of positive cultures in each group. C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide-clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide-clindamycin group. There were no statistically significant differences between treatment arms. The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

Diagnostic accuracy of clinical tests directed to the long head of biceps tendon in a surgical population: a combination of old and new tests

11-09-2019 – Afonso Cardoso, Pedro Amaro, Luís Barbosa, Ana M. Coelho, Raul Alonso, Luís Pires

Journal Article

Our objective was to examine the clinical utility of old and new clinical tests directed to the long head of the biceps tendon (LHBT) and to quantify the importance of proper test interpretation. A consecutive 65 patients scheduled to undergo arthroscopic surgery were selected. Before surgery, 5 clinical tests were performed: Speed, Yergason, upper cut, biceps resisted flexion (BRF), and modified BRF (m
BRF) using a dumbbell. Pain in an area other than the bicipital groove was noted. The presence of LHBT disease was assessed at arthroscopy, and the clinical utility of the tests was calculated. The upper cut test was the most sensitive test and the one with the lowest negative likelihood ratio (0.90 and 0.26, respectively); the Yergason test was the most specific and the one with the highest positive likelihood ratio (0.83 and 2.20, respectively). BRF strength did not correlate with an LHBT lesion. The m
BRF test has a sensitivity of 0.34 and a specificity of 0.75. Higher age predicted an increased risk of an LHBT lesion (1.2 times). Different interpretations of the tests can result in a difference of up to 29 percentage points in performance (ie, sensitivity). Our results suggest that the upper cut test should be used as a screening test and that after a positive result, the Speed and the Yergason tests should be used as confirmatory tests.

Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial

11-09-2019 – Yaiza Lopiz, Borja Alcobía-Díaz, María Galán-Olleros, Carlos García-Fernández, Amanda López Picado, Fernando Marco

Journal Article

Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3- or 4-part PHFs in elderly patients. This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3- and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), Euro
Qol 5 Dimensions, and EQ-VAS scores. We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes at 12 months’ follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P = .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P = .075); the VAS scores were 1.6 and 0.9, respectively (P = .011); the physical SF-12 scores were 36 and 37, respectively (P = .709); the mental SF-12 scores were 43 and 42, respectively (P = .625); the Euro
Qol 5 Dimensions scores were 0.89 and 0.92, respectively (P = .319); and the EQ-VAS scores were 65 and 67, respectively (P = .604). This study yields important evidence for the treatment of complex PHFs in elderly patients suggesting minimal benefits of RSA over nonoperative treatment for displaced 3- and 4-part PHFs. At short-term follow-up, the main advantage of RSA appeared to be less pain perception.

Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty

07-08-2019 – Anirudh K. Gowd, Avinesh Agarwalla, Nirav H. Amin, Anthony A. Romeo, Gregory P. Nicholson, Nikhil N. Verma, Joseph N. Liu

Journal Article

We aimed to demonstrate that supervised machine learning (ML) models can better predict postoperative complications after total shoulder arthroplasty (TSA) than comorbidity indices. The American College of Surgeons-National Surgical Quality Improvement Program database was queried from 2005-2017 for TSA cases. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, extended length of stay (>3 days), surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, and readmission. Each SML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and the positive predictive value (PPV) of complications. We identified a total of 17,119 TSA cases. Mean age, BMI, and length of stay were 69.5 ± 9.6 years, 31.1 ± 6.8, and 2.0 ± 2.2 days. Percentage hematocrit, BMI, and operative time were of highest importance in outcome prediction. SML algorithms outperformed ASA classification models for predicting any adverse event (71.0% vs. 63.0%), transfusion (77.0% vs. 64.0%), extended length of stay (68.0% vs. 60.0%), surgical site infection (65.0% vs. 58.0%), return to the operating room (59.0% vs. 54.0%), and readmission (64.0% vs. 58.0%). SML algorithms demonstrated the greatest PPV for any adverse event (62.5%), extended length of stay (61.4%), transfusion (52.2%), and readmission (10.1%). ASA classification had a 0.0% PPV for complications. With continued validation, intelligent models could calculate patient-specific risk for complications to adjust perioperative care and site of surgery.

Rasch analysis of the Disabilities of the Arm, Shoulder and Hand (DASH) instrument in patients with a humeral shaft fracture

02-12-2019 – Esther M.M. Van Lieshout, Kiran C. Mahabier, Wim E. Tuinebreijer, Michael H.J. Verhofstad, Dennis Den Hartog, Hugo W. Bolhuis, P. Koen Bos, Maarten W.G.A. Bronkhorst, Milko M.M. Bruijninckx, Jeroen De Haan, Axel R. Deenik, P. Ted Den Hoed, Martin G. Eversdijk, J. Carel Goslings, Robert Haverlag, Martin J. Heetveld, Albertus J.H. Kerver, Karel A. Kolkman, Peter A. Leenhouts, Sven A.G. Meylaerts

Journal Article

The Disabilities of the Arm, Shoulder and Hand (DASH) instrument was developed to assess the disability experienced by patients with any musculoskeletal condition of the upper extremity and to monitor change in symptoms and upper-limb function over time. The 30 items are scored on a 5-point rating scale. The Dutch-language version of the DASH instrument (DASH-DLV) has been examined with the classical test theory in patients with a humeral shaft fracture. This study aimed to examine the DASH-DLV with a more rigorous and extensive analysis by applying the Rasch model. Data of 400 patients included in a multicenter, prospective study comparing operative and nonoperative treatment of adult patients with a humeral shaft fracture were used. The person-item map, item fit statistics, reliability, response category ordering, and dimensionality were examined. Raw data were converted to linear measures using the Rasch model. The DASH-DLV showed a good fit to the Rasch model, except for item 26 (“Tingling [pins and needles] in your arm, shoulder or hand”). The person reliability was 0.92. In general, the category functioning of the 5-point rating scale was working well. Dimensionality analysis revealed that the DASH-DLV is a unidimensional scale. Differential item functioning for sex was not detected, and only item 26 exhibited differential item functioning as a function for age. The DASH-DLV fits the stringent Rasch model in a clinical situation with a group of adult patients with a humeral shaft fracture. Adequate measurement for scientific research can be obtained to evaluate longitudinal intervention research.

Viewing perspective malrotation influences angular measurements on lateral radiographs ofxa0the scapula

01-12-2019 – Thomas Suter, Nicola Krähenbühl, C. Kalebb Howell, Yue Zhang, Heath B. Henninger

Journal Article

Accurate and reliable assessment of acromial tilt (ATA) and slope (ASA) angles have been important in the clinical evaluation of degenerative and traumatic rotator cuff tears. This study analyzed the influence of radiographic viewing perspective on the ATA and ASA and developed criteria to identify true lateral (TL) view radiographs. Three-dimensional computed tomographic (CT) reconstructions of 52 scapulae without rotator cuff tears or osteoarthritis were studied. Digitally reconstructed radiographs (DRRs) were aligned to obtain a TL view. In 10 random scapulae, incremental ante- and retroversion and up- and downward rotation views were generated (10° increments, ±30°), and ATA and ASA were measured by 2 observers. Clinically applicable criteria were developed and validated to identify TL views. The mean ATA and ASA on TL views were 33°±4° (range 23°-42°) and 22°±7° (8°-43°), respectively. Mixed effect models showed that DRRs malpositioned in 20° and 30° anteversion and downward rotation decreased the ATA (P ≤ .030). DRRs malpositioned in anteversion and >10° of up- and downward rotation demonstrated a significantly decreased ASA (P ≤ .047). Intra- and interobserver reliability was excellent for TL views (intraclass correlation coefficient ≥ 0.95) but decreased with increasing viewing angle. Anatomic landmark criteria were capable of identifying TL-view radiographs with sensitivity of 81% and specificity of 82%. Both ATA and ASA were significantly affected by malposition in anteversion and downward rotation of the scapula. Reliable ASA measurement was more susceptible in up- and downward rotation than the ATA. New visual criteria can identify TL-view radiographs and should be used in future studies to ensure consistency in ATA and ASA measurement.

Beige fibro-adipogenic progenitor transplantation reduces muscle degeneration and improves function in a mouse model of delayed repair of rotator cuff tears

01-12-2019 – Carlin Lee, Mengyao Liu, Obiajulu Agha, Hubert T. Kim, Xuhui Liu, Brian T. Feeley

Journal Article

Muscle atrophy and fatty infiltration (FI) are common occurrences following rotator cuff (RC) tears. Tears of all sizes are subject to muscle degeneration. The degree of muscle degeneration following RC tears is highly correlated with repair success and functional outcomes. We have recently discovered that muscle fibro-adipogenic progenitors (FAPs) can differentiate into uncoupling protein 1 (UCP-1)-expressing beige adipocytes and induce muscle regeneration. This study evaluated the potential of local cell transplantation of beige adipose FAPs (BAT-FAPs) to treat RC muscle degeneration in a murine model of RC repair. BAT-FAPs were isolated from muscle in UCP-1 reporter mice by flow cytometry as UCP-1 Cell transplantation diminished fibrosis, FI, and atrophy and enhanced vascularization in both delayed repair models. Cell transplantation resulted in improved shoulder function as assessed with gait analysis in both the delayed repair models. BAT-FAPs significantly reduced muscle degeneration and improved shoulder function after RC repair. BAT-FAPs hold significant promise as a therapeutic adjunct to repair for patients with advanced RC pathology.

Inflammatory cytokines and matrix metalloproteinases in the synovial fluid after intra-articular elbow fracture

01-12-2019 – Elizabeth P. Wahl, Alexander J. Lampley, Angel Chen, Samuel B. Adams, Dana L. Nettles, Marc J. Richard

Journal Article

Post-traumatic elbow contracture remains a common and challenging complication with often unsatisfactory outcomes. Although the etiology is unknown, elevated or abnormal post-fracture synovial fluid cytokine levels may result in the migration of fibroblasts to the capsule and contribute to capsular pathology. Thus, the purpose of this study was to characterize the cytokine composition in the synovial fluid fracture hematoma of patients with intra-articular elbow fractures. The elbow synovial fluid fracture hematoma of 11 patients with intra-articular elbow fractures was analyzed for CTXII (C-terminal telopeptides of type II collagen [a cartilage breakdown product]) as well as 15 cytokines and matrix metalloproteinases (MMPs) including interferon γ, interleukin (IL) 1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10. The uninjured, contralateral elbow served as a matched control. Mean concentrations of each factor were compared between the fluid from fractured elbows and the fluid from control elbows. The levels of 14 of 15 measured cytokines and MMPs-interferon γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-3, MMP-9, and MMP-10-were significantly higher in the fractured elbows. In addition, post hoc power analysis revealed that 10 of 14 significant differences were detected with greater than 90% power. The mean concentration of CTXII was not significantly different between groups. These results demonstrate a proinflammatory environment after fracture that may be the catalyst to the development of post-traumatic elbow joint contracture. The cytokines with elevated levels were similar, although not identical, to the cytokines with elevated levels in studies of other weight-bearing joints, indicating the elbow responds uniquely to trauma.

Can small glenospheres with eccentricity reduce scapular notching as effectively as large glenospheres without eccentricity? A prospective randomized study

01-12-2019 – Carlos Torrens, Joan Miquel, Raquel Martínez, Fernando Santana

Journal Article

The objective of this study was to analyze whether small glenospheres with eccentricity were comparable to large glenospheres in scapular notch development. This prospective randomized study included 82 patients who had undergone a reverse shoulder arthroplasty with a 2-year follow-up period. After randomization, 43 patients were allocated to receive a 42-mm glenosphere and 39 patients were allocated to receive a 38-mm glenosphere with 2 mm of eccentricity. Scapular notch development was defined after examination of an anteroposterior radiograph at the end of follow-up. Functional outcomes were recorded using the Constant score before surgery and at the end of follow-up. Scapular notch development was present in 16.6% of patients who received a 42-mm glenosphere and 34.2% of patients who received a 38-mm eccentric glenosphere. No significant difference was found between the groups with the number of cases available (P = .07). Functional outcomes significantly increased from preoperatively to postoperatively in both groups, with no significant difference found between them (P = .77). The mean glenosphere overhang measure was 6.3 mm in patients with a 42-mm glenosphere and 6.0 mm in those with a 38-mm eccentric glenosphere (P = .68). No significant differences were noted between patients with a scapular notch and patients without a scapular notch in terms of functional outcomes. Small glenospheres with eccentricity fared slightly worse than large glenospheres regarding scapular notch development, even though no significant differences were noted. Functional outcomes were comparable between the 2 designs.

Brachial plexus palsy after clavicle fracture: 3xa0cases

01-12-2019 – Tomohiro Saito, Tomohiro Matusmura, Katsushi Takeshita

Journal Article

Brachial plexus palsy after clavicle fracture is extremely rare. We experienced 3 cases of brachial plexus palsy after clavicle fracture and investigated the findings that such patients have in common and the clinical results of these cases. We retrospectively analyzed the data of 3 patients with clavicle fracture who had no neurovascular symptoms at the time of the initial injury but gradually developed brachial plexus palsy within 1 month after the injury. The patients were aged 70, 62, and 68 years; 2 patients were male and 1 was female. The patients’ backgrounds and clinical results were assessed. All patients had a displaced middle-third clavicle fracture and underwent conservative therapy with a figure-8 bandage. The intervals between fracture and symptoms of brachial plexus palsy were 8, 30, and 14 days. The times from symptoms of brachial plexus palsy to surgery were 27, 75, and 28 days. In all patients, surgery revealed a ruptured subclavius muscle and abnormal development of granulation tissue around the fracture site, compressing the brachial plexus. Open reduction and plate fixation was performed in 2 patients, and clavicle resection was performed in 1 patient. The intervals between surgery and full recovery of muscle strength were 11, 6, and 6 months. The findings our 3 patients with brachial plexus palsy after clavicle fracture had in common are old age, middle-third displaced clavicle fracture, and abnormal development of granulation tissue around the fracture site. Surgical intervention yielded good clinical outcomes.

A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty

30-11-2019 – Peter Lapner, J Whitcomb Pollock, Tinghua Zhang, Sara Ruggiero, Franco Momoli, Adnan Sheikh, George S. Athwal

Journal Article

Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty. Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events. We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months’ follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99). No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.

Surgeon charges and reimbursements are declining compared with hospital payments for shoulder arthroplasty

30-11-2019 – Aaron J. Casp, J. Michael Smith, Stephen F. Brockmeier, Brian C. Werner

Journal Article

The relationship between surgeon and hospital charges and payments for total shoulder arthroplasty (TSA) has not been well examined. The goal of this study was to report trends and variation in hospital charges and payments compared with surgeon charges and payments for TSA. The 5% Medicare sample was used to capture hospital and surgeon charges and payments for TSA from 2005 to 2014. Two values were calculated: (1) the charge multiplier (CM), which is the ratio of hospital to surgeon charges, and (2) the payment multiplier (PM), which is the ratio of hospital to surgeon payments. The year-to-year variation and regional trends in patient demographic characteristics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. The study included 10,563 patients. Per-patient hospital charges increased from $33,836 to $67,177 (99.9% increase), whereas surgeon charges increased from $4284 to $4674 (9.1% increase) (the CM increased from 7.9 to 14.4, P < .0001). Hospital payments increased from $8758 to $14,167 (61.8%), whereas surgeon payments decreased from $1028 to $884 and the PM increased from 8.5 to 16.0 (P < .0001). The LOS decreased significantly (P < .0001), whereas the Charlson Comorbidity Index remained stable. Both the CM (r Hospital charges and payments relative to surgeon charges and payments have increased substantially for TSA despite stable patient complexity and a decreasing LOS. These results encourage the need for future studies with detailed cost analyses to identify the reasons for hospital and surgeon financial malalignment.

The association between race/ethnicity and outcomes following primary shoulder arthroplasty

27-11-2019 – Ivan A. Garcia, Priscilla H. Chan, Heather A. Prentice, Ronald A. Navarro

Journal Article

Although prior studies have reported health disparities in total knee and hip arthroplasty, few have evaluated the effect of race/ethnicity on total shoulder arthroplasty, particularly in a setting in which patients have uniform access to care. Because the procedural volume of shoulder arthroplasty has increased dramatically over the past decade, evaluating the association between race/ethnicity and postoperative outcomes is warranted. We sought to evaluate racial/ethnic disparities in adverse postoperative events within a universally insured shoulder arthroplasty cohort in an integrated health care system. An integrated health care system’s registry was used to identify patients who underwent elective primary (total or reverse) shoulder arthroplasty from 2005 to 2016. Four mutually exclusive race/ethnicity groups were investigated: white, Asian, black, and Hispanic. Racial differences were evaluated using Cox proportional hazards regression for all-cause revision and conditional logistic regression for 90-day unplanned readmissions and 90-day emergency department (ED) visits while adjusting for confounders. Of the 8360 shoulder procedures, 2% were performed in Asian patients; 5%, black patients; 9%, Hispanic patients; and 84%, white patients. Compared with white patients, Hispanic patients had a 44% lower revision risk (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97). Black patients had a 45% higher likelihood of a 90-day ED visit (odds ratio, 1.45; 95% confidence interval, 1.12-1.89). We found minority groups to have revision and unplanned readmission risks that were similar to or lower than those of white patients. However, black patients had a higher likelihood of ED visits. Further investigation is needed to determine the reasons for this disparity and identify interventions to mitigate unnecessary ED visits.

Teres major transfer to restore external rotation of shoulder in Erbxa0palsy patients

25-11-2019 – Ashraf M. Abdelaziz, Wael Aldahshan, Faisal Ahmed Hashem Elsherief, Mahmoud Ali Ismail, Amro A. Fouaad, Wael Sh Mahmoud, Tharwat Al Akeed, Mahmoud Mabrouk Said

Journal Article

The lack of external rotation and shoulder abduction as sequelae of obstetric brachial plexus palsy requires a release of the subscapularis muscle associated with tendon transfer of the internal rotator of the shoulder. The aim of this study was to present the results of a teres major transfer to the infraspinatus tendon. This study included 20 patients (9 boys and 11 girls) with a mean age of 3 years 8 months (range, 1.5-14 years). The average follow-up time was 42 months (range, 12-48 months) to determine whether external rotation weakness and internal rotation contracture sequelae were managed by anterior release of the subscapularis and teres major tendon transfer to the infraspinatus tendon. We found marked improvement in shoulder abduction from 67° before surgery to 158° after surgery. We also found marked improvements in active external rotation from 8° before surgery to 85° after surgery and in passive external rotation from 0° preoperatively to 72° postoperatively. Two cases showed a loss of the last degrees of internal rotation, but this improved after physiotherapy. Anterior release of the subscapularis tendon with a teres major transfer to the infraspinatus tendon significantly improves shoulder function in Erb palsy patients with internal rotation contracture.

Tailored treatment of aneurysmal bone cyst of the scapula: en bloc resection for the body and extended curettage for the neck and acromion

25-11-2019 – Khodamorad Jamshidi, Milad Haji Agha Bozorgi, Mikaiel Hajializade, Abolfazl Bagherifard, Alireza Mirzaei

Journal Article

The acromion and neck of the scapula are essential components of shoulder function, but the body section is less critical. We treated aneurysmal bone cysts (ABCs) of the neck and ‏acromion with extended curettage and ABCs of the body with en bloc resection.‏ This article reports on local recurrence and the functional outcomes of this approach. Seventeen patients with primary ABCs of the scapula were included in this retrospective study. We treated 10 patients with extended curettage and bone grafting and 5 patients with en bloc resection. In 2 cases, both the body and neck were involved. We treated these patients with a combination of curettage and resection. We used the Musculoskeletal Tumor Society score for functional assessment of outcomes. The mean age of the patients was 20.5 ± 7.4 years. One local recurrence occurred in patients who underwent extended curettage and bone grafting (1 of 12 cases, 8.3%). No recurrence was observed in patients who underwent en bloc resection alone. The mean Musculoskeletal Tumor Society score was 27.9 ± 1 in patients who underwent curettage alone and 24.86 ± 0.7 in patients who underwent en bloc resection alone or in combination with curettage (P < .001). Despite the higher risk of local recurrence after curettage, this method can be selected for the treatment of ABCs of the acromion and neck of the scapula to minimize shoulder disability. For the body of the scapula, en bloc resection is a more reasonable treatment, despite a higher rate of functional impairment.

The effect of short-stem humeral component sizing on humeral bone stress

13-11-2019 – G. Daniel G. Langohr, Jacob Reeves, Christopher P. Roche, Kenneth J. Faber, James A. Johnson

Journal Article

Several humeral stem design modifications for shoulder arthroplasty, including reduced stem length, changes to metaphyseal geometry, and alterations to implant surface texture, have been introduced to reduce stress shielding. However, the effect of changes in the diametral size of short-stem humeral components remains poorly understood. The purpose of this finite element study was to quantify the effect of varying the size of short-stem humeral components on the changes in bone stress from the intact state to the reconstructed state. Three-dimensional models of 8 male cadaveric humeri (mean age, 68 ± 6 years; all left-sided humeri) were constructed from computed tomography data using Mimics software. Each humerus was then reconstructed with 2 short-stem components (Exactech Preserve), one having a larger diametral size (SH+) and one having a smaller diametral size (SH-). Modeling was conducted for loading states consistent with 45° and 75° of abduction, and the resulting changes in bone stress compared with the intact state and the expected bone response were determined. The smaller (SH-) short-stem implant produced humeral cortical and trabecular bone stresses that were closer to the intact state than the larger (SH+) short-stem implant at several locations beneath the humeral head resection (P ≤ .032). A similar trend was observed for expected bone response, where the smaller (SH-) short-stem implant had a smaller proportion of bone that was expected to resorb following reconstruction compared with the larger (SH+) short-stem implant for several slice depths in the medial quadrant (P ≤ .02). These findings may indicate that smaller short-stem components are favorable in terms of stress shielding.

Does the etiology of a failed hemiarthroplasty affect outcomes when revised to a reverse shoulder arthroplasty?

11-11-2019 – Kimberly J. Franke, Kaitlyn N. Christmas, Katheryne L. Downes, Mark A. Mighell, Mark A. Frankle

Journal Article

The purposes of this study were to evaluate patient outcomes after revision of hemiarthroplasty to reverse shoulder arthroplasty (RSA) based on initial pathology, to determine the re-revision rate, and to identify characteristics that may predict subsequent re-revision. A total of 207 shoulder hemiarthroplasty, bipolar prosthesis, and humeral resurfacing cases revised to RSA between January 2004 and January 2017 were reviewed. Outcome measures included shoulder motion and American Shoulder and Elbow Surgeons and Simple Shoulder Test (SST) scores. Sixteen RSAs underwent re-revision. A case-control study with each revised RSA matched to 4 controls based on age, sex, and minimum 2-year follow-up was performed to evaluate for factors predicting re-revision. The mean time from initial hemiarthroplasty to RSA was 3.6 years (range, 0.1-20 years). There were 114 patients with a minimum of 2 years’ follow-up (mean, 57 months; range, 24-144 months). The most common initial diagnoses for hemiarthroplasty were fracture (n = 72), cuff tear arthropathy (CTA) (n = 22), and osteoarthritis (OA) (n = 20). Overall mean scores and range-of-motion values were as follows: American Shoulder and Elbow Surgeons score, 59 (95% confidence interval [CI], 54-64); SST score, 4 (95% CI, 4-5); forward flexion, 106° (95% CI, 96°-116°); and abduction, 95° (95% CI, 85°-105°). Compared with fracture cases, CTA cases had better forward flexion (P = .01) and abduction (P = .006) and OA cases had better SST scores (P = .02) and abduction (P = .04). The re-revision rate was 7.7% at a mean of 31 months (range, 0-116 months), with the most common diagnosis being fracture (10 of 16 cases). Humeral loosening (8 of 16 cases) was the most common failure mechanism, and larger glenosphere sizes were more likely to be revised. Functional outcome scores of hemiarthroplasty cases revised to RSA were better for patients with OA than for patients with CTA or fracture. Cases of hemiarthroplasty for fracture had decreased motion after revision to RSA compared with CTA and OA. Humeral loosening was the most common failure mechanism.

Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis

22-10-2019 – Annika Theodoulou, Jeganath Krishnan, Edoardo Aromataris

Journal Article, Review

A systematic review was performed to investigate the impact of obesity on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). Electronic databases and the grey literature were searched for studies that evaluated the influence of obesity (body mass index ≥ 30 kg/m The findings suggested that patients who were obese were at increased odds of a dislocation (OR, 2.49; 95% confidence interval [CI], 2.32-2.66), fracture (OR, 1.92; 95% CI, 1.77-2.08), and revision (OR, 1.49; 95% CI, 1.40-1.58) following TSA or RTSA. Conversely, obesity had no influence on the odds of an unscheduled return to the operating theater (OR, 0.83; 95% CI, 0.43-1.61). Postoperative forward flexion in patients who were obese differed from that in patients who were not obese (WMD, -9.8°; 95% CI, -17.53° to -2.07°); however, no differences in other functional measures including abduction (WMD, -0.78; 95% CI, -7.27 to 5.71) and external rotation (WMD, -1.41; 95% CI, -5.11 to 2.29) were found. Although patients who were obese reported significantly higher levels of pain (WMD, 1.13; 95% CI, 0.21 to 2.06), the difference was not clinically relevant. Surgeons should consider advising patients who are obese of the greater risk of dislocation, fracture, and revision when considering elective TSA or RTSA. Findings are limited by confounding variables but further our understanding of additional risks associated with pre-existing obesity, which will promote better-informed decisions prior to proceeding with surgery.

Transverse ligament of the elbow joint: an anatomic study of cadavers

17-07-2019 – Kentaro Kimata, Masaya Yasui, Hiroki Yokota, Shuichi Hirai, Munekazu Naito, Takashi Nakano

Journal Article

The medial collateral ligament of the elbow joint consists of the anterior oblique ligament (AOL), posterior oblique ligament (POL), and transverse ligament (TL). This study aimed to clarify the structure of the TL, with a focus on the continuity between the TL and AOL. A total of 42 cadavers (18 males, 24 females) were dissected at Aichi Medical University between 2016 and 2018. Cases of elbow deformity or atrophy were excluded, and 60 elbows (15 males, 15 females) were dissected to assess the fibers of both the TL and AOL using a stereomicroscope. The TL could be detected in all elbows and always continued to the AOL. The TL was classified into 2 types. The TLs continuing to the distal half of the AOL (type I) were observed in 44 elbows (73.3%), whereas the TLs continuing to the entire AOL (type II) were found in 16 elbows (26.7%). Type II TLs were significantly more frequently observed in the elbows of females than in those of males (P = .041). Stereomicroscopic observation revealed that the TL fibers entered perpendicularly to the distal half of the AOL in both types. The TL frequently continues to the distal half of the AOL, but rarely continues to the entire AOL. The TLs continuing to the entire AOL were more frequently detected in the elbows of females than in those of males. The TL possibly contributes to medial elbow stability via its continuity to the AOL.

Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace

29-07-2019 – David L. Bernholt, Spencer P. Lake, Ryan M. Castile, Christopher Papangelou, Oliver Hauck, Matthew V. Smith

Journal Article

Current ulnar collateral ligament (UCL) reconstruction techniques are substantially less stiff and demonstrate lower load to failure compared with the native UCL. UCL repair with the addition of an internal brace has demonstrated superior biomechanical performance compared with docking UCL reconstruction, but internal bracing has not yet been used in UCL reconstruction. To evaluate the time-zero biomechanical performance of a UCL docking technique reconstruction with and without an internal brace compared with native UCL properties. Twelve matched pairs of cadaveric elbows were dissected and fixed at 90° for biomechanical testing. A cyclic valgus torque protocol was used to test the anterior band of the UCL in native specimens. After native specimens were failed, palmaris grafts were used for a docking reconstruction with or without internal brace and were subjected to the same valgus torque test protocol. Torsional stiffness, ultimate failure torque, and ulnohumeral gapping were determined. Stiffness in UCL reconstructions using a standard docking technique (3.0 ± 0.4 N m/deg) were significantly less stiff (P < .001) than native UCL (4.0 ± 0.8 N m/deg), whereas reconstructions using an internal brace (3.6 ± 0.6 N m/deg) were not different (P = .120) compared with native. Ultimate failure torque for standard docking (18.3 ± 4.1 N m) was significantly lower (P < .001) than native UCL (36.9 ± 10.1 N m), whereas the internal brace samples (35.3 ± 9.8 N m) were not different (P = .772) than native. UCL reconstruction with an internal brace augmentation provides superior stiffness and time-zero failure strength when compared with the standard docking technique.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty

17-07-2019 – Anirudh K. Gowd, Michael D. Charles, Joseph N. Liu, Simon P. Lalehzarian, Brandon C. Cabarcas, Brandon J. Manderle, Gregory P. Nicholson, Anthony A. Romeo, Nikhil N. Verma

Journal Article

Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients’ sense of functional improvement after shoulder arthroplasty. Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Arthroscopic visualization of the medial collateral ligament of the elbow

14-07-2019 – Jae-Man Kwak, Erica Kholinne, Yucheng Sun, Jin-Young Park, Kyoung-Hwan Koh, In-Ho Jeon

Journal Article

This study aimed to determine the extent to which the medial collateral ligament (MCL) can be visualized during a standard posterior arthroscopic view of the elbow. Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. Standard elbow arthroscopy was performed on each specimen using a standard posterior portal for visualization with a 30° arthroscope. The most distal borders of the visible part of the MCL were marked using a spinal needle and tagged using nylon sutures. Subsequently, the elbow was dissected. The overall surface area of the entire MCL and that defined by the suture tags were calculated for each specimen. The mean area of the visible part of the MCL represented 48% of the mean overall area. The arthroscopically tagged part of the posterior band of the MCL represented <50% of the entire MCL. Arthroscopic visualization was not available for most of the posterior bands of the MCL. Less than half of the MCL is visible with a 30° arthroscope from standard posterior portal. Thus, sole reliance on arthroscopic visualization with this manner is not enough to release of the MCL. The variable effort is required to improve the limited visualization during the procedure. Moreover, the individual attention is essential to protect the ulnar nerve because the ulnar nerve is very close to the MCL especially to the anterior band.

Development of a clinical risk calculator for prolonged opioid use after shoulder surgery

08-07-2019 – Allen D. Nicholson, Hafiz F. Kassam, Jacqueline L. Steele, Natalie R. Passarelli, Theodore A. Blaine, David Kovacevic

Journal Article

Understanding risk factors associated with prolonged opioid use to help mitigate abuse and develop presurgical screening programs to identify at-risk patients is paramount. The purpose of this study was to develop and validate a clinical risk assessment tool to preoperatively predict prolonged opioid use after shoulder surgery. A total of 561 patients who underwent shoulder surgery within a tertiary health care system were identified, and opioid prescription data were retrospectively collected from the Connecticut Prescription Monitoring and Reporting System. The inclusion criteria were patients aged 18 years or older, and the exclusion criteria were patients not registered in the Connecticut Prescription Monitoring and Reporting System. Quantities of opioids prescribed were documented. Demographic characteristics, surgery type, medications, and medical comorbidities were identified by chart abstraction. Logistic regression was used to calculate odds ratios of patients using opioids longer than 6 weeks, and multivariate analysis was performed on 10 identified patient factors. A concordance index was used to calculate the discriminatory ability of a nomogram to predict prolonged opioid use. Multivariate analysis demonstrated that opioid use prior to surgery, insurance type, procedure type, body mass index, smoking status, and psychiatric disorders were responsible for prolonged opioid use. The prediction accuracy of this model was good, with a calculated concordance index of 0.766 (95% confidence interval, 0.736-0.820). We present a preoperative predictive calculator to help identify at-risk patients and quantify their risk of prolonged opioid use after shoulder surgery. This is a valuable clinical decision-making tool to identify patients benefitting from referral to pain management specialists and to possibly reduce the risk of opioid abuse and addiction.

Preserving the radial head in comminuted Mason type III fractures without fixation to the radial shaft: a mid-term clinical and radiographic follow-up study

22-10-2019 – Markus Gregori, Stephanie Zott, Stefan Hajdu, Tomas Braunsteiner

Journal Article

The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications. The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P). Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain. Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.

Management of rheumatoid arthritis of the elbow with a convertible total elbow arthroplasty

22-10-2019 – Jason A. Strelzow, Tym Frank, Kevin Chan, George S. Athwal, Kenneth J. Faber, Graham J.W. King

Journal Article

Total elbow arthroplasty (TEA) is commonly performed in patients with rheumatoid arthritis (RA). The purpose of this study was to compare outcomes and complications of unlinked and linked TEA using a convertible system in patients with RA. All patients with RA who underwent TEA at a single center with a minimum of 2 years’ follow-up were reviewed. Demographic information, patient-reported outcome scores, functional outcome assessments, and radiographic parameters were evaluated at most recent follow-up. We evaluated 82 patients (27 with unlinked TEA and 55 with linked TEA) with RA. The mean age at surgery was 61 ± 10 years, with a mean follow-up period of 6 ± 4 years. Demographic characteristics were similar between groups, with the exception of longer follow-up in the unlinked group (8 years vs. 5 years, P = .001). No differences in range of motion were noted. Elbow strength was similar other than pronation strength (74% ± 8% for unlinked vs. 100% ± 8% for linked, P = .03). The mean Mayo Elbow Performance Index was 83 ± 16; Patient Rated Elbow Evaluation score, 15 ± 18; and Quick
DASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score, 34 ± 20. No differences in the rates of reoperation (17% vs. 24%, P = .4), complications (32% vs. 31%, P = .4), or revisions (13% vs. 17%, P = .3) were found between unlinked and linked devices. Four patients with instability, all with unlinked designs, underwent revision to a linked design. Four patients, all with linked designs, underwent revision for aseptic loosening of smooth short-stem ulnar components. TEA using a convertible implant design provides good patient-reported outcomes at mid-term follow-up in patients with RA. Our study was unable to detect a difference in the use of either unlinked or linked implant designs; further large comparison trials are needed.

Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial

26-08-2019 – Niloofar Dehghan, Matthew Furey, Laura Schemitsch, Bill Ristevski, Thomas Goetz, Emil H. Schemitsch, Canadian Orthopaedic Trauma Society (COTS), Michael McKee

Journal Article

Total elbow arthroplasty (TEA) is a reliable treatment for elderly patients with comminuted intra-articular distal humeral fractures. However, the longevity and long-term complications associated with this procedure are unknown. The objectives of this study were to examine long-term outcomes and implant survival in elderly patients undergoing TEA for fracture. Patients from a previously published randomized controlled trial of 42 patients in which TEA was compared with open reduction-internal fixation (ORIF) were followed up long term. Patients were aged 65 years or older with comminuted intra-articular distal humeral fractures. Outcomes included patient-reported grading of function and pain, revision surgical procedures, and implant survival. Data were obtained for 40 patients, 15 treated with ORIF and 25 treated with TEA, with a mean follow-up period of 12.5 years for surviving patients and 7.7 years for deceased patients. The reoperation rate was 3 of 25 in the TEA group and 4 of 15 in the ORIF group (P = .39). Of the 25 patients with TEAs, only 1 required (early) revision arthroplasty; 7 were living with their original arthroplasty, and 15 died with a well-functioning implant in situ. Three were lost to follow-up. TEA is an effective and reliable procedure for the treatment of comminuted distal humeral fractures in the elderly patient. Our study reveals reliable implant long-term survival, with no patient requiring a late revision. For the majority of these patients, a well-performed TEA will give them a well-functioning elbow for life and will be the last elbow procedure required.

Latissimus dorsi transfer for massive posterosuperior rotator cuff tears: what affects the postoperative outcome?

03-07-2019 – Mohamed Moursy, Jonas Schmalzl, Aditya S. Kadavkolan, Niko Bartels, Lars-Johannes Lehmann

Journal Article

The management of irreparable posterosuperior rotator cuff tears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs. Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analog scale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologic evaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval. In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). Active flexion increased from 83° ± 47° to 144° ± 35°; abduction, from 69° ± 33° to 134° ± 42°; and external rotation, from 24° ± 18° to 35° ± 21°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%. LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.

Radiographic outcomes of impaction-grafted standard-length humeral components in total shoulder and ream-and-run arthroplasty: is stress shielding an issue?

06-07-2019 – Patrick J. Denard, Jason E. Hsu, Anastasia Whitson, Moni B. Neradilek, Frederick A. Matsen

Journal Article

The purpose of this study was to evaluate humeral stress shielding in shoulder arthroplasties performed with a smooth, standard-length humeral stem fixed with impaction autografting. Two-year outcomes were evaluated for 48 ream-and-run arthroplasties and 78 total shoulder arthroplasties (TSAs) performed at a single institution. Postoperative radiographs were analyzed for adaptive changes, calcar osteolysis, and component shift or subsidence. Radiographic outcomes were analyzed for associations with patient demographic characteristics, humeral stem filling ratios, and glenoid loosening; clinical outcomes were assessed using the Simple Shoulder Test. At 2 years after surgery, the ream-and-run procedures showed partial calcar osteolysis in 9 cases (19%). The TSAs showed partial calcar osteolysis in 19 cases (24%) and complete calcar osteolysis in 2 (3%). Humeral component subsidence or component shift was observed in 3 ream-and-run procedures (6%) and in 8 TSAs (10%). These radiographic findings were not significantly associated with patient demographic characteristics, canal-filling ratios, or clinical outcomes. When inserted with impaction autografting, a smooth, standard-length humeral stem offers a secure bone-preserving approach for humeral component fixation in shoulder arthroplasty. These results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods.

Arthroscopic repair of isolated subscapularis tears: clinical outcome and structural integrity with a minimum follow-up of 4.6 years

08-07-2019 – Anita Hasler, Glenn Boyce, Alex Schallberger, Bernhard Jost, Sabrina Catanzaro, Christian Gerber

Journal Article

After isolated subscapularis repair, improvement in shoulder function has been reported at short-term review. The purpose of this study was to determine whether arthroscopic subscapularis repair provides durable improvement in objective and subjective shoulder function with a low structural retear rate. All patients treated with arthroscopic repair of an isolated subscapularis tear between August 2003 and December 2012 with a minimum follow-up period of 4.6 years were identified from our database. A number of patients in our study cohort underwent a prior complete midterm assessment, which allowed a subgroup analysis to detect changes in structural integrity and corresponding function. Clinical and radiographic outcomes, including outcomes on conventional radiography and magnetic resonance imaging or ultrasound, were assessed. The study enrolled 36 shoulders with a mean patient age of 57.7 years (range, 31-75 years; standard deviation, 10.6 years). The mean follow-up period was 8.6 years (range, 4.6-13.9 years; standard deviation, 2.44 years). Internal rotation to the thoracic vertebrae was achieved in 94% of cases and was significantly improved (P < .001) compared with the preoperative situation. The mean relative Constant score improved from 68% preoperatively to 93% at final follow-up (P < .001). Magnetic resonance imaging evaluation showed a rerupture rate of 2.7% (1 of 36 shoulders). Twenty patients underwent previous complete midterm assessment (mean, 2.9 years; range, 1-4.5 years), with comparisons between midterm and long-term follow-up showing comparable results without statistically significant deterioration. Functional and subjective improvements in shoulder function are maintained at a mean follow-up of more than 8 years after isolated subscapularis repair and are associated with a low structural failure rate of the repair.

Arthroscopic rotator cuff repair: magnetic resonance arthrogram assessment of tendon healing

13-05-2019 – Craig M. Ball

Journal Article

Many poor outcomes after arthroscopic rotator cuff (RC) repair relate to failure of tendon healing. The purposes of this study were to provide a better understanding of the magnetic resonance arthrography (MRA) characteristics of the RC tendon repair site after arthroscopic RC repair and to examine how these findings influence patient-reported outcome measures (PROMs) and the presence of persistent symptoms. We reviewed 48 shoulders (13 female and 35 male patients; average age, 53.8 years) at a minimum of 6 months (average, 11.4 months) after arthroscopic RC repair (average tear size, 2.2 cm). All patients completed PROMs and underwent MRA assessment. Detailed analysis of the RC repair site was undertaken, with findings correlated with clinical outcomes and PROMs. The average preoperative American Shoulder and Elbow Surgeons (ASES) score of 39.5 improved to 92.8 (P 50%) were observed in 7 patients (14.6%), with no effect on outcomes (average ASES score of 95.2 and satisfaction score of 9). There were 2 recurrent full-thickness tears (4.2%), and 4 patients (8.3%) had a failure in continuity. The average ASES score in these 6 cases of failure was 76 (P < .001). Structural abnormalities on MRA are common after RC repair but do not always result in clinical failure. However, our results suggest that an ASES score of less than 80 may be useful when considering postoperative imaging, especially in a patient with ongoing pain more than 6 months after surgery.

A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management

10-07-2019 – Alejandro Cortes, Noah J. Quinlan, Mark R. Nazal, Shivam Upadhyaya, Kyle Alpaugh, Scott D. Martin

Journal Article

Magnetic resonance imaging (MRI) is often used to evaluate the integrity of the rotator cuff in patients with suspected full-thickness rotator cuff tears or other cuff tendinopathies. The value of advanced imaging value comes into question when it is used as the initial musculoskeletal imaging test before a trial of conservative therapy in patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy. A prospective study of a group of patients suspected to have cuff tendinopathy based on clinical findings was performed. Every patient underwent MRI and was offered an initial trial of conservative management. Patients had an average follow-up of 28.3 ± 5.3 months after imaging to determine whether surgery was performed. A total of 51 patients were included in this study. Of this cohort, 46 (90.2%) patients did not go on to surgical intervention, whereas 5 (9.8%) patients did at an average 68.3 days after imaging. These results suggest that over 90.2% of patients (46 of 51) had premature MRI, posing an unnecessary economic burden of $181,619 in advanced imaging charges. The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level.

Reverse total shoulder arthroplasty provides stability and better function than hemiarthroplasty following resection of proximal humerus tumors

14-08-2019 – Timothy W. Grosel, Darren R. Plummer, Joshua S. Everhart, James C. Kirven, Chance L. Ziegler, Joel L. Mayerson, Thomas J. Scharschmidt, Jonathan D. Barlow

Journal Article

Tumors may necessitate resection of a substantial portion of the proximal humerus and surrounding soft tissues, making reconstruction challenging. We evaluated outcomes in patients undergoing treatment of tumors of the proximal humerus with reverse total shoulder arthroplasty (r
TSA) or shoulder hemiarthroplasty. Patients who underwent r
TSA (n = 10) or shoulder hemiarthroplasty (n = 37) for tumors of the proximal humerus in 2009 to 2017 were reviewed. Of these patients, 27 had died, leaving 20 for review. The mean follow-up period of the survivors was 27.1 months. They were evaluated clinically and contacted to determine the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. Postoperative complications occurred in 13 hemiarthroplasty patients (34%). Tumor recurrence occurred in 3 hemiarthroplasty patients (7.9%), whereas in the r
TSA group, 1 patient (10%) had a postoperative complication, with no recurrences. One hemiarthroplasty patient required revision surgery with r
TSA to improve shoulder function. Six dislocations and two subluxations occurred in the hemiarthroplasty group, whereas no subluxations occurred in the r
TSA group (P = .14). Mean range of motion was 85° of forward flexion for r
TSA patients (n = 10) compared with 28° for hemiarthroplasty patients (P < .001). The mean American Shoulder and Elbow Surgeons score was 63 for hemiarthroplasty patients (n = 5) and 59 for r
TSA patients (n = 4). The mean Simple Shoulder Test scores were 3.8 and 2.4, respectively. The mean visual analog scale pain scores were 2.4 and 2.5, respectively. Reverse total shoulder arthroplasty can reproducibly reconstruct the shoulder in patients requiring oncologic proximal humerus resection. Patients have good outcomes, better range of motion, and no increase in instability rates compared with hemiarthroplasty.

Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy

14-07-2019 – Joseph N. Liu, Avinesh Agarwalla, Anirudh K. Gowd, Anthony A. Romeo, Brian Forsythe, Nikhil N. Verma, Gregory P. Nicholson

Journal Article

The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA. The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination. A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA. RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.

Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes?

06-07-2019 – Paul DeVito, Hyrum Judd, Andy Malarkey, Leah Elson, Emmanuel McNeely, Derek Berglund, Rushabh Vakharia, Jonathan C. Levy

Journal Article

The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.

Functional workspace and patient-reported outcomes improve after reverse and total shoulder arthroplasty

10-07-2019 – Alex Ngan, Weiyuan Xiao, Patrick F. Curran, Wo Jan Tseng, Li Wei Hung, Chantal Nguyen, Robert Matthew, Benjamin Ma, Jeffrey Lotz, Brian T. Feeley

Journal Article

Low-cost motion analysis systems (LCMASs) have emerged as easy and practical methods to measure the functional workspace (FWS). Thus, we ventured to apply an LCMAS, the Kinect2 gaming camera, to evaluate the FWS in patients with shoulder osteoarthritis (OA) and patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). A cross-sectional study of participants with OA (n = 53), TSA (n = 70), and RTSA (n = 34) was performed. The FWS as measured by an LCMAS, the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, and the Patient-Reported Outcomes Measurement Information System (PROMIS) score were collected. For participants who underwent TSA or RTSA, the FWS was evaluated at 6, 12, and 24 months postoperatively. The correlation of the FWS with the ASES score and PROMIS score was determined. Significance was set at P < .05. Patients who underwent TSA or RTSA had a significantly higher FWS than patients with shoulder OA at almost all time points. Patients who underwent TSA had a significantly higher FWS than patients who underwent RTSA at 24 months after surgery. PROMIS and ASES scores showed strong correlations with the FWS in patients who underwent TSA (R = 0.75 [P < .001] and R = 0.83 [P < .001], respectively) and RTSA (R = 0.84 [P < .001] and R = 0.73 [P < .001], respectively). The FWS measured by an LCMAS is an easy and low-cost method to quantify the reachable space of the hand in patients and shows strong correlations with patient-reported outcome measures. This may be a useful tool to assess upper-extremity range of motion before and after shoulder arthroplasty.

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

30-07-2019 – Michael P. Carducci, Zachary R. Zimmer, Andrew Jawa

Journal Article

Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome. Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome. A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement. Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications.

Comparison of outcomes of 2 surgical treatments for proximal humerus giant cell tumors: a multicenter retrospective study

06-07-2019 – Wen-zhe Bai, Shi-bing Guo, Wei Zhao, Xiu-chun Yu, Ming Xu, Kai Zheng, Yong-cheng Hu, Feng Wang, Guo-chuan Zhang

Journal Article

The incidence of giant cell tumors in the proximal humerus is low. We evaluated 2 surgical treatments for giant cell tumors of the proximal humerus and postoperative upper-extremity function. This study retrospectively analyzed the clinical data of 27 cases of giant cell tumors of the proximal humerus at 4 Chinese medical centers specializing in bone oncology collected between January 2002 and June 2015. All patients were followed up for more than 2 years. The surgical procedures performed for treatment included curettage in 14 patients and segmental resection in 13. The Campanacci grade, occurrence of pathologic fracture, surgical method, complications, and Musculoskeletal Tumor Society score were recorded for each cohort. The recurrence rate was 7.1% in the curettage group and 15.4% in the segmental resection group. Other postoperative complications occurred in 4 patients with segmental resection, including resorption of the osteoarticular allograft in 2, subluxation of the glenohumeral joint in 1, and prosthetic loosening and exposure in 1. A significant difference in postoperative upper-extremity function was noted between the 2 groups (P < .001). Postoperative upper-extremity function in the curettage group was significantly better than that in the segmental resection group. Segmental resection and reconstruction with a large segmental osteoarticular allograft were considered unadvisable. We suggest that extensive curettage should be selected to treat proximal humerus giant cell tumors as much as possible.

Preoperative corticosteroid joint injections within 2 weeks of shoulder arthroscopies increase postoperative infection risk

03-07-2019 – Sarah Bhattacharjee, Wonyong Lee, Michael J. Lee, Lewis L. Shi

Journal Article

There is currently no consensus regarding the safe timing interval between corticosteroid shoulder injections and future shoulder arthroscopies. Our study assessed the relationship between preoperative corticosteroid injection timing and shoulder arthroscopy infectious outcomes. We used an insurance database to identify and sort all shoulder arthroscopy patients by corticosteroid shoulder injection history within 6 months before surgery. Patients who received injections were stratified by the timing of their most recent preoperative injection. The overall infection rate and rate of severe infections requiring treatment through intravenous antibiotics or surgical débridement in the 6-month postoperative period were compared using χ We identified 50,478 shoulder arthroscopy patients, of whom 4115 received injections in the 6-month preoperative period. We found a significant increase in both the overall infection rate (P < .0001) and severe infection rate (P < .0001) in patients who received injections within 2 weeks before surgery (n = 79; 8.86% and 6.33%, respectively) compared with those who received no injections in the 6-month preoperative period (n = 46,363; 1.56% and 0.55%, respectively). No other significant differences were observed. Our results suggest that in patients who have received corticosteroid injections, shoulder arthroscopic procedures may be safely performed after at least 2 weeks has passed since the most recent injection to minimize the risk of postoperative infection. In addition, procedures performed within 2 weeks of an injection may increase the risk of postoperative infection.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness

28-08-2019 – Amr A. Abdelrahman, Amr Ibrahim, Khalid Abdelghaffar, Tarek Mohamed Ghandour, Diaa Eldib

Journal Article

The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using Tight
Rope in acromioclavicular joint dislocation III and IV. Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG). Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up

18-07-2019 – Alison I. Murphy, Eoghan T. Hurley, Daire J. Hurley, Leo Pauzenberger, Hannan Mullett

Journal Article, Review

The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years’ follow-up. Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years’ follow-up. Statistical analysis was performed using SPSS software. Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy. Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.

Does Medicaid expansion improve access to care for the first-time shoulder dislocator?

16-09-2019 – Graham E. Kirchner, Nicholas J. Rivers, Emily F. Balogh, Samuel R. Huntley, Paul A. MacLennan, Brent A. Ponce, Eugene W. Brabston, Amit M. Momaya

Journal Article

The purpose of this study was to assess the effect of individual state Medicaid expansion status on access to care for shoulder instability. Four pairs of Medicaid expanded (Louisiana, Kentucky, Iowa, and Nevada) and unexpanded (Alabama, Virginia, Wisconsin, and Utah) states in similar geographic locations were chosen for the study. Twelve practices from each state were randomly selected from the American Orthopedic Society for Sports Medicine directory, resulting in a sample size of 96 independent sports medicine offices. Each office was called twice to request an appointment for a fictitious 16-year-old first-time shoulder dislocator with either in-state Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance. A total of 91 physician offices in 8 states were contacted by telephone. An appointment was obtained at 36 (39.6%) offices when calling with Medicaid and at 74 (81.3%) offices when calling with BCBS (P < .001). Thirty-five (38.5%) offices were able to make appointments for both types of insurance, 39 (42.9%) for only BCBS, 1 (1.1%) for only Medicaid, and 16 (17.5%) for neither. For Medicaid patients, an appointment was booked in 13 (27.7%) clinics from Medicaid expanded states and in 23 (52.3%) clinics from unexpanded states (P = .016). For a first-time shoulder dislocator, access to care is more difficult with Medicaid insurance compared with private insurance. Within Medicaid insurance, access to care is more difficult in Medicaid expanded states compared with unexpanded states. Medicaid patients in unexpanded states are twice as likely as those in expanded states to obtain an appointment.

Nationwide trends in management of proximal humeral fractures: an analysis of 77,966 cases from 2008 to 2017

20-08-2019 – Andrew S. McLean, Nathan Price, Stephen Graves, Alesha Hatton, Fraser J. Taylor

Journal Article

There is no consensus as to the treatment of proximal humeral fractures (PHFs), particularly in elderly patients. There is increasing evidence that nonoperative management may have similar functional outcomes to operative management, which is potentially conflicting with increasingly improved surgical techniques and implants. The aim of this study was to investigate the changes in the incidence and management of PHFs across Australia over a 10-year period. We retrospectively reviewed all hospitalizations of patients with PHFs from 2 Australian national health care databases from 2008 to 2017. We recorded the incidence of PHFs and annual utilization rates of commonly used treatment options including nonoperative management, hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA), and open reduction-internal fixation (ORIF). The incidence of PHFs increased from 26.8 per 100,000 person-years in 2008 to 45.7 per 100,000 person-years in 2017. There was a decrease in operative management from 2008 to 2017, with 32.5% and 22.8% of all PHFs treated operatively in 2008 and 2017, respectively (P = .001). ORIF use decreased significantly from 76.6% to 72.6% (P = .004). RTSA use increased significantly from 4.1% to 24.5% (P < .001). HA use decreased significantly from 19.3% to 3% (P < .001). Whereas the incidence of PHFs increased, the operative management of PHFs decreased significantly from 2008 to 2017, particularly in patients aged 65 years or older. This decrease in operative management was in part due to a significant decrease in ORIF and HA use in patients aged 65 years or older. There was a significant increase in RTSA use.

Core set of unfavorable events of shoulder arthroplasty: an international Delphi consensus process

23-09-2019 – Laurent Audigé, Hans-Kaspar Schwyzer, Ville Äärimaa, Tjarco D. Alta, Marcus Vinicius Amaral, Alison Armstrong, Arthur van Noort, Steve Bale, Shaul Beyth, Andreas Bischof, Desmond J. Bokor, Mario Borroni, Stig Brorson, Peter Brownson, Stefan Buchmann, Eduard Buess, Benjamin Cass, Cormac Kelly, Vincenzo De Cupis, Philippe Debeer

Journal Article

Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies. A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement. Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue). A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

The use of biologics for the elbow: a critical analysis review

06-10-2019 – Jason L. Dragoo, Molly C. Meadows

Journal Article, Review

There is significant interest in biologic treatment options to improve the healing environment and more rapidly decrease symptoms in many conditions around the elbow. Despite fairly widespread use of biologic agents such as platelet-rich plasma (PRP) in the elbow, there is a lack of clear evidence in the literature to support its use. The potential impact of these biologic agents must be evaluated with evidence from high-quality studies, particularly considering the high financial burden these treatments often impose on patients. The aim of this review is to provide an evidence-based summary of the biologic augmentation options available for use by the physician treating painful conditions of the elbow and to identify areas where further research is warranted.

The role of biologic agents in the management of common shoulder pathologies: current state and future directions

06-10-2019 – James B. Carr, Scott A. Rodeo

Journal Article, Review

The field of orthopedic surgery has seen a rapid increase in the use of various biologic agents for the treatment of common musculoskeletal injuries. Most biologic agents attempt to harness or mimic naturally occurring growth factors, cytokines, and anti-inflammatory mediators to improve tissue healing and recovery. The most commonly used biologic agents are platelet-rich plasma and cells derived from bone marrow aspirate and adipose tissue. These agents have become increasingly popular despite a relative dearth of clinical data to support their use. Much confusion exists among patients and physicians in determining the role of these agents in treating common shoulder pathologies, such as glenohumeral osteoarthritis, rotator cuff tears, and tendinopathy. This article reviews the basic science and clinical evidence for the most commonly used biologic agents in the management of common shoulder pathology.

The New York Times, May 13, 2019: “Stem Cell Treatments Flourish With Little Evidence That They Work”

06-10-2019 – Jason L. Dragoo, Scott A. Rodeo


All-arthroscopic, guided Eden-Hybbinette procedure using suture-button fixation for revision of failed Latarjet

25-07-2019 – Pascal Boileau, Christophe Duysens, David Saliken, Devin B. Lemmex, Nicolas Bonnevialle

Journal Article

To report the results of a guided arthroscopic Eden-Hybbinette procedure, using suture button for iliac crest bone graft fixation, in a series of patients with a prior failed Latarjet and persistent glenoid bone loss. Seven consecutive patients (5 males, 2 females, mean age: 30.7 years [range, 17-47 years]) with recurrent anterior dislocations and glenoid deficiency greater than 20% underwent the all-arthroscopic revision procedure. The iliac crest bone graft and suture-button device (Bone-Link) were shuttled through the rotator interval. Specific drill guides were used and a suture tensioning device allowed bone graft compression. Previous broken screw shafts (3 patients) were left in situ. Graft placement and healing was assessed postoperatively with computed tomography imaging. No neurologic injury or hardware problems occurred, and no patient required further surgery. On computed tomography scan, optimal positioning (flush and under the equator) and healing of the bone graft was observed in all patients. At a mean follow-up of 21 months (range, 12-39 months), all but one patient were satisfied and had a stable shoulder; 5 returned to sports. The Constant score increased from 32 to 81 points, and the subjective shoulder value from 31% to 87% (P < .001). The Walch-Duplay and Rowe scores averaged 85.7 (range, 65-100) points and 86.4 (range, 70-100) points, respectively. Recurrence of anterior shoulder instability after a failed Latarjet procedure can be successfully treated by an all-arthroscopic Eden-Hybbinette procedure. Suture-button fixation is reliable and permits optimal positioning and predictable healing of the new bone graft; in addition, it is an appropriate fixation option in the setting of retained broken hardware.

A new pathologicxa0classification for elbow stiffness based on our experience in 216 patients

05-11-2019 – Ziyang Sun, Juehong Li, Haomin Cui, Hongjiang Ruan, Wei Wang, Cunyi Fan

Journal Article

Elbow stiffness commonly causes functional impairment and upper-limb disability. This study aimed to develop a new pathologic classification to further understand and standardize elbow arthrolysis from a new perspective, as well as to determine clinical outcomes. Extension-flexion dysfunction was classified into 4 types: EF Mean range of motion (ROM) increased from 40° preoperatively to 118° at final follow-up; 88% of patients regained ROM of 100° or greater. The forearm rotation arc (FRA) with forearm rotation dysfunction increased from a preoperative mean of 76° to 128°; 82% of patients regained an FRA of 100° or greater. The mean Mayo Elbow Performance Index (MEPI) increased from 63 to 91 points; the proportion of patients with good or excellent results was 95%. EF This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes.

Is surgical duration associated with postoperative complications in primary shoulder arthroplasty?

05-11-2019 – Hasani W. Swindell, Rami G. Alrabaa, Venkat Boddapati, David P. Trofa, Charles M. Jobin, William N. Levine

Journal Article

Surgical duration is an independent predictor of short-term adverse outcomes after a variety of orthopedic procedures, both arthroscopic and open. However, this association in shoulder arthroplasty remains unclear. The purpose of this study was to identify the association between surgical duration and postoperative complications, as well as increased use of health care resources, after shoulder arthroplasty. Primary shoulder arthroplasty procedures performed from 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgical duration was divided into 3 cohorts: (1) surgical procedures lasting less than 90 minutes, (2) those lasting between 90 and 120 minutes, and (3) those lasting more than 120 minutes. Baseline patient characteristics and outcome variables were compared using bivariate analysis. Outcome variables were compared using multivariate analysis. Overall, 14,106 patients were identified. Longer surgical duration was significantly associated with younger age, male patients, higher body mass index, and use of general anesthesia, (P < .001 for each), as well as smoking history (P < .39). Relative to operative times shorter than 90 minutes, surgical procedures lasting more than 120 minutes had higher rates of any complication (P = .002), return to the operating room (P = .008), urinary tract infection (P = .02), non-home discharge (P < .001), blood transfusion (P < .001), and unplanned 30-day hospital readmission (P = .03). Increasing surgical duration was associated with a variety of postoperative medical complications and increased use of health care resources including discharge to acute care facilities, blood transfusions, and hospital readmission. These data suggest that surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors.

Benzoyl peroxide use transiently decreases Cutibacterium acnes load on the shoulder

05-11-2019 – Grant Duvall, Samir Kaveeshwar, Anshum Sood, Ashley Klein, Katrina Williams, Logan Kolakowski, Jim Lai, Blessing Enobun, S. Ashfaq Hasan, R. Frank Henn, Mohit N. Gilotra

Journal Article

Cutibacterium acnes is the most common pathogen in shoulder prosthetic joint infections. Short-contact benzoyl peroxide (BPO) solutions effectively reduce C acnes loads on the shoulder preoperatively. It is unknown how long the effect of BPO lasts. We evaluated C acnes counts 1 week after BPO application. We hypothesized that BPO would decrease C acnes burden with a rebound after 1 week. Screening of 102 healthy volunteers with no history of shoulder surgery or C acnes infection was performed to establish bacterial counts. Thirty-four participants were selected based on an established threshold. Each was given BPO 5% for 3 consecutive days of application on either the left or right shoulder as indicated by a random number generator. Deep sebaceous gland cultures were obtained with a detergent scrub technique before BPO application, after 3 days of use, and 1 week after BPO treatment commenced. The differences between the logarithmic reduction and the logarithmic rebound at the anterior, lateral, and posterior sites were statistically significant. Anteriorly, the average log reduction was -0.44 and the average log rebound was 0.69 (P = .003). Laterally, reduction was -0.64 and rebound was 0.74 (P = .003). Posteriorly, reduction was -0.63 and rebound was 0.78 (P = .008). At the axilla, reduction was -0.40 and rebound was 0.31 (P = .10). The differences in C acnes burden between pretreatment and 1-week counts at all sites were not statistically significant. A significant decrease in C acnes burden occurred after BPO application but was not permanent. Significant rebound occurred just 1 week later.

Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study

05-11-2019 – Erin F. Ransom, David P. Adkison, David P. Woods, Martim C. Pinto, Jun Kit He, James Vann Worthen, Eugene W. Brabston, Brent A. Ponce

Journal Article

Most anatomic total shoulder arthroplasty (ATSA) techniques release and reattach the subscapularis tendon. The risk of failed healing is a widely recognized complication. The purpose of this study was to radiographically compare a traditional deltopectoral (DP) approach and a superolateral subscapularis sparing (SSS) technique through the rotator interval. A single, independent, blinded, reviewer analyzed preoperative and postoperative radiographs of patients undergoing ATSA performed by a single surgeon. The reviewer assessed humeral head height, humeral head medial offset, humeral head diameter, head-neck angle, humeral head centering, and coracohumeral offset, and used the anatomic reconstruction index (ARI) to evaluate overall reconstruction quality. There were 70 SSS and 20 DP patients included. When comparing preoperative with postoperative differences, we found that there was no difference between groups in humeral head height (P = .19), humeral head medial offset (P = .38), and coracohumeral offset (P = .07). The DP group had a mean humeral head diameter oversizing of 1.4 mm, whereas the superolateral group had an undersizing of 2.8 mm (P < .001). The head-neck angle difference of the SSS approach was 2° greater than that found with the DP group (P < .001). The humeral head centering in the DP group was 7% displaced vs. 12% with the SSS group (P = .001) relative to the glenoid size. The ARI was 7.35 for the DP group and 6.93 for the SSS group (P = .50). Radiographic comparison of these 2 ATSA techniques identified no statistical significant difference in 4 of 7 radiographic measurements and ARI. The SSS ATSA is a reasonable approach that yields similar radiographic measurements as a traditional DP total shoulder arthroplasty approach.

Mapping physical functions of the shoulder to American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information System scores

05-11-2019 – Aaron M. Roberts, Ilya Voloshin

Journal Article

We sought to correlate physical functions of the shoulder to American Shoulder and Elbow Surgeons (ASES) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. We reviewed 3300 patient encounters with completed ASES scores, representing 2447 patients. Patients were seen for shoulder-related complaints. The most common diagnoses were rotator cuff disease (56%) and arthritis (9%); 54% and 46% of encounters were in operatively and nonoperatively treated patients, respectively. A total of 2632 PROMIS Physical Function (PF), 2574 PROMIS Pain Interference (PI), and 959 PROMIS Upper Extremity (UE) scores were simultaneously collected with the ASES form. The ASES form specifically asks about the ability to perform 8 physical functions. Receiver operating characteristic curves were calculated to determine 90% positive predictive value (PPV) and 90% negative predictive value (NPV) cutoffs for the ability to perform at high function for the ASES and PROMIS-PF, -UE, and -PI scores for the entire shoulder cohort and for rotator cuff disease and arthritis subgroups. ASES scores had consistently excellent ability, PROMIS-UE scores had reasonable to excellent ability, and PROMIS-PF and PROMIS-PI scores had overall reasonable ability to determine high- and low-function states. For reaching a high shelf in the rotator cuff disease subgroup, the 90% NPV and PPV cutoff scores were 41 and 66, respectively, for the ASES instrument. For reaching a high shelf in the arthritis subgroup, the cutoff scores were 50 and 78, respectively, for the ASES instrument. The 90% NPV and PPV cutoffs for each score, physical function, and diagnosis group were depicted by visual representations (“maps”) for easier interpretation. Shoulder physical functions were mapped to outcome scores. Physical function mapping adds clinical meaning to the orthopedic literature, facilitating improved, more-informed decision making between physicians and patients.

Favorable outcome of extended curettage for the treatment of unifocal chronic sclerosing osteomyelitis of clavicle: a case series

02-11-2019 – Khodamorad Jamshidi, Mohsen Heidari, Abolfazl Bagherifard, Alireza Mirzaei

Journal Article

Chronic sclerosing osteomyelitis (CSO) of the clavicle, especially its unifocal subset, is scarcely reported, and little is known about its characteristic features and treatment. We aim to describe the characteristic features and outcome of treatment in a series of patients with unifocal CSO of the clavicle. In a retrospective study, we identified 6 patients with a diagnosis of unifocal CSO of the clavicle. All patients underwent a core needle biopsy, and histologic examination confirmed the diagnosis. Laboratory investigations included the white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and bacteriologic culture. We used plain radiographs, computed tomography scanning, and magnetic resonance imaging for the radiologic evaluation. The median age of the patients was 16.5 years (range, 10-29 years). The ESR and CRP level were elevated in 5 cases. The bacterial culture results were negative in all cases. Sclerosis was the main radiologic symptom. Other radiologic features such as bone expansion, cystic change, periosteal reaction, cortex destruction, and soft-tissue edema could accompany sclerosis. Anti-inflammatory medications temporarily and slightly reduced the symptoms. Four patients underwent extended curettage, in whom the clinical, radiologic, and laboratory symptoms considerably subsided. In the 2 patients who did not agree to undergo surgical intervention, the clinical and radiologic symptoms fluctuated at the follow-up visits. Unifocal CSO of the clavicle is associated with negative bacterial culture results, but the ESR and CRP level are frequently elevated. The symptoms fluctuate if not adequately treated. Extended curettage could be regarded as the treatment of choice.

A 3-dimensional comparison of hand and power reamers in accuracy of glenoid retroversion correction

02-11-2019 – Michael Scheidt, Michael Wesolowski, Dane Salazar, Nickolas Garbis

Journal Article

The study objective was to compare the reaming congruency of hand, power, and visual feedback axial alignment-guided (Marksman) reamers on glenoid models. We hypothesized that (1) a significant difference in average reaming deviation would be found between reamer types and (2) less ream-to-ream variation would occur with the Marksman reamer. Retroversion correction of 18 identical Sawbones glenoid models was conducted using either a hand, power, or Marksman reamer with a 40-mm curvature radius. Glenoid correction with either 0° or 10° reaming was conducted in triplicate sets for each reamer. Reamed glenoid computed tomography images were 3-dimensionally reconstructed using Mimics Medical software (version 21.0). Congruency between the glenoid surface and a 3-dimensional sphere with a 40-mm curvature radius was analyzed. Average deviation and ream-to-ream variance were compared between the hand, power, and Marksman reamer groups. The power reamer demonstrated the smallest median deviation (0.08 mm; interquartile range [IQR], 0.07-0.19 mm), followed by the Marksman (0.09 mm; IQR, 0.08-0.17 mm) and hand (0.11 mm; IQR, 0.10-0.13 mm) reamers. Kruskal-Wallis analysis indicated no significant difference in deviation among the 3 reaming methods (P = .42). The Marksman reamer demonstrated the least variance (0.0034 mm), followed by the power (0.0076 mm) and hand (0.0093 mm) reamers. The results of the Conover squared ranks test indicated no significant difference in variance among the 3 reaming methods (P = .32). Our findings showed no statistically significant difference in the accuracy or consistency of reaming between reamer types. Trends showed less variance in the Marksman reamer group compared with the hand and power reamer groups, although differences in variation between groups were not statistically significant.

Little benefit of surgical anchor and suture removal and of antibiotic therapy beyond 6xa0weeks in infected rotator cuff repair

02-11-2019 – Elias Ammann, Ilker Uçkay, Samy Bouaicha, Karl Wieser, Dominik C. Meyer

Journal Article

The purpose of this study was to investigate the benefit of surgical anchor and/or suture removal and prolonged antibiotic therapy in acute and chronic infections of rotator cuff repair (RCIs). A single-center cohort and case-control study (Cox regression) was performed. Outcome variables were remission of infection and postinfection reoperations due to failed tendon healing for mechanical causes. All analyses were performed with an emphasis on anchor and suture retention or removal. We identified 54 primary RCIs (44 men; median age 54 years) that were surgically revised (10 by open débridement and 44 by arthroscopy). Twenty-eight (52%) were not intact on revision surgery (débridement) – 10 were partially and 18 totally re-ruptured. The median number of surgical revisions was 1 (range, 1-3), and the median duration of postsurgical antibiotic therapy was 75 days. After a minimal follow-up of 2 years, 8 infections (8/54, 15%) recurred. Twenty patients needed a revision surgery; in all of those 20 patients, intraoperative samples were negative for infection. By multivariate analysis, anchor removal at the first revision influenced neither remission (hazard ratio [HR] 0.9, 95% confidence interval [CI] 0.4-2.0) nor the need for later revision surgery due to mechanical sequelae (HR 0.6, 95% CI 0.1-1.4). The corresponding HRs for suture removal were 0.9 (95% CI 0.4-1.7) and 0.4 (95% CI 0.1-1.2). Likewise, the numbers of revision surgery (HR 0.5, 95% CI 0.2-1.3) and antibiotics beyond 6 weeks failed to influence remission (HR 1.1, 95% CI 0.4-3.1). In our RCI cohort, the removal of anchors or sutures, repeated revision surgery, or an antibiotic therapy beyond 6 weeks failed to improve remission or to reduce sequelae.

Factors predictive of Cutibacterium periprosthetic shoulder infections: axa0retrospective study of 342 prosthetic revisions

02-11-2019 – Frederick A. Matsen, Anastasia Whitson, Moni B. Neradilek, Paul S. Pottinger, Alexander Bertelsen, Jason E. Hsu

Journal Article

Cutibacterium are the most common cause of periprosthetic shoulder infections, as defined by ≥2 deep cultures. Established Cutibacterium periprosthetic infections cannot be resolved without prosthesis removal. However, the decision for implant removal must be made from an assessment of infection risk before the results of intraoperative cultures are finalized. We hypothesized that the risk for a Cutibacterium infection is associated with characteristics that are available at the time of revision arthroplasty. In a retrospective review of 342 patients having prosthetic revisions between 2006 and 2018 for whom definitive deep culture results were available, we used univariate and multivariate analyses to compare the preoperative and intraoperative characteristics of 101 revisions with Cutibacterium periprosthetic infections to the characteristics of 241 concurrent revisions not meeting the definition of infection. Patients with definite Cutibacterium periprosthetic infections were younger (59 ± 10 vs. 64 ± 12, P < .001), were more likely to be male (91% vs. 44%, P < .001), were more likely to have had their index procedure performed for primary osteoarthritis (54% vs. 39%, P = .007), were more likely to be taking testosterone supplements (8% vs. 2%, P = .02), had lower American Society of Anesthesiologists scores (1.9 ± 0.7 vs. 2.3 ± 0.7, P < .001), and had lower body mass indices (29 ± 5 vs. 31 ± 7, P = .005). Patients with definite Cutibacterium periprosthetic infections also had significantly higher preoperative loads of Cutibacterium on their unprepared skin surface (1.7 ± 0.9 vs. 0.4 ± 0.8, P < .001) and were more likely to have the surgical finding of synovitis (41% vs. 16%, P < .001). The risk of definite Cutibacterium periprosthetic infections is associated with observations that can be made before or at the time of revision arthroplasty.