Making Sense of Topical Pain Relief Options: Comparing Topical Analgesics in Efficacy and Safety.

CONTEXT: In patients with musculoskeletal (MSK) conditions, pain is the leading contributor to disability and significantly limits mobility and dexterity. This narrative review describes the efficacy and safety of topical analgesics in common use today. EVIDENCE ACQUISITION: Secondary literature gained via a literature search using PubMed.gov and the Cochrane library were used. STUDY DESIGN: Recent literature (2000-2023) on several major classes of topical analgesics and topical delivery systems were reviewed to provide strength of recommendation taxonomy (SORT) levels. A total of 86 articles were reviewed. LEVEL OF EVIDENCE: Level 2. RESULTS: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and cabbage leaf wraps (CLW) appear to be best suited for multiple types of acute MSK pain, and topical nitroglycerin is helpful when used specifically for rotator cuff pain in patients seeking relief while performing activities of daily living and willing to treat for long periods of time. For compounded topical formulations, it may be better to offer single agent creams based on patient preferences. Little data support the use of cryotherapy. Traumeel could be a promising natural analgesic that compares with diclofenac. Topical lidocaine appears best suited for postherpetic neuropathic pain. O24 is a reasonable alternative with a low risk profile to treat pain in patients with fibromyalgia syndrome. CONCLUSION: Choice of topical agents should be guided by current evidence accounting for type of pain, medication side effects, patient comorbidities, as well as patient preference, convenience, and cost. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): Of the topical analgesics and modalities reviewed, SORT level A evidence was found for topical NSAID use in decreasing MSK pain, topical lidocaine for postherpetic neuralgia, and nitroglycerin patches for treating rotator cuff pain if used for prolonged periods of time. Alternative treatments such as CLW and Traumeel show promising results (SORT level B).

Outcomes of revision versus re-revision reverse total shoulder arthroplasty: A case-control-matched cohort study.

Background: The increasing incidence of reverse total shoulder arthroplasties (RTSA) has led to an increase in revision surgery. We aimed to compare patients undergoing re-revision RTSA to a matched cohort undergoing first-revision RTSA. Methods: A retrospective review of all revision RTSAs was performed at a single institution. Sixteen shoulders that underwent re-revision RTSA were matched 1:3 to shoulders that underwent revision RTSA with a minimum two-year follow-up. Outcome scores including the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Short-Form 12 (SF-12), Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test (SST) scores, range of motion (ROM), and improvement from preoperative to postoperative outcomes after re-revision RTSA were assessed. Additionally, postoperative outcomes after re-revision RTSA were compared to patients that underwent first revision RTSA and subsequently compared to the minimal clinically important difference (MCID) values for the outcome scores and ROM measurements assessed. Results: Sixteen shoulders that underwent re-revision RTSA and 78 revision RTSAs met the final inclusion criteria to be included in this study. Significant improvement from preoperative to postoperative re-revision RTSA was seen in the ASES score (p = 0.046), SPADI score (p = 0.044), SST (p = 0.008), abduction (p = 0.016), and elevation (p = 0.025), but not the SF-12 score (p = 0.396), external rotation (p = 0.449), or internal rotation (p = 0.451). Outcomes after revision RTSA were found to be superior to outcomes after re-revision RTSA for all outcome scores (ASES p = 0.029, SF-12 p = 0.018, SPADI p = 0.003) except the SST score (p = 0.080) and all ROM measures (p > 0.05 for all). Internal rotation was equivalent postoperatively between both groups. From preoperative to postoperative re-revision RTSA, the mean improvement exceeded the MCID for the SST score, abduction, forward elevation, and external rotation. When comparing postoperative revision RTSA to postoperative re-revision RTSA, the mean difference between revision and re-revision RTSA exceeded the MCID for the SPADI score and external rotation. The complication rate was 19% in shoulders undergoing first revision and 41% in shoulders undergoing re-revision RTSA. Conclusion: Patients undergoing re-revision RTSA receive improvement in clinical outcomes, but do not achieve outcomes comparable to those achieved after first revision RTSA.

The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty.

Aims: We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients. Methods: A retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up. Results: We included 428 primary aTSAs with a mean follow-up of 2.4 years (SD 0.6). Our cohort consisted of 251 non-smokers, 138 former smokers who quit a mean 21 years (SD 14) prior to surgery (25 pack-years (SD 22)), and 39 current smokers (23 pack-years (SD 20)). At two- to four-year follow-up, former smokers had less favourable SPADI, SST, and FE strength compared to non-smokers, and current smokers had less favourable SPADI, SST, ASES score, UCLA score, Constant-Murley score, FE, abduction, and ER strength compared to non-smokers. Non-smokers exhibited higher revision-free survival rates at two, five, eight, and ten years postoperatively compared to former smokers and current smokers, who had similar rates. Conclusion: Our study suggests that smoking has a negative effect on aTSA functional outcomes that may persist even after quitting.

The Effect of Smoking on Outcomes of Reverse Total Shoulder Arthroplasty.

BACKGROUND: The effect of smoking status on clinical outcomes in reverse total shoulder arthroplasty (rTSA) has not been thoroughly characterized. We sought to compare pain and functional outcomes, complications, and revision-free survivorship between current smokers, former smokers, and non-smokers undergoing primary rTSA. METHODS: We retrospectively reviewed a prospectively-collected shoulder arthroplasty database from 2004-2020 to identify patients who underwent primary rTSA. Three cohorts were created based on smoking status: current smokers, former smokers, and non-smokers. Outcome scores (SPADI, SST, ASES, UCLA, Constant), range of motion (ROM) (external rotation [ER], forward elevation [FE], abduction, internal rotation [IR]) and shoulder strength (ER, FE) evaluated at 2-4-year follow-up were compared between cohorts. The incidence of complication and revision-free implant survivorship were evaluated. RESULTS: We included 676 primary rTSAs, including 38 current smokers (44±47 pack-years), 84 former smokers who quit on average 20±14 years (range: 0.5-57 years) prior to surgery (38±32 pack-years), and 544 non-smokers. At 2-4-year follow-up, current smokers had less favorable SPADI, SST, ASES scores, UCLA scores, and Constant scores compared to former smokers and non-smokers. On multivariable analysis, current smokers had less favorable SPADI, SST, ASES score, UCLA score, and Constant score compared to non-smokers. There were no significant differences between cohorts in complication rate and revision-free survivorship. CONCLUSION: Our data showed that current smokers may have poorer functional outcomes after rTSA compared to former smokers and non-smokers despite the incidence of complications and revision surgery not differing significantly between cohorts.

Survivorship and Clinical Outcomes of Reverse Total Shoulder Arthroplasty in Patients with Large Glenoid Defects Using the Stilting Technique and a Baseplate with Central Ingrowth Cage and Peripheral Locking Screws.

BACKGROUND: Stilting is a novel technique used in reverse shoulder arthroplasty (RSA) in patients with significant glenoid bone loss. This technique utilizes peripheral locking screws placed behind an unseated portion of the baseplate, to transmit forces from the baseplate to the cortical surface of the glenoid, without the need for bone grafting. The stilted screw, once locked, provides a fixed angle point of support for an unseated aspect of a baseplate. The primary advantages of this technique are reduced cost compared to a custom implant and reduced operative time compared to bone grafting. METHODS: We conducted a retrospective, non-randomized, comparative cohort study of 41 patients underwent primary Reverse Shoulder Arthroplasty (RSA) using the Stilting Technique with the Exactech Equinoxe Reverse System (Gainesville, FL, USA) at a single, academic center from the years 2004-2021. Exclusion criteria included age under 18 or over 100, and oncologic or acute fracture RSA indications. Operative data was documented, including implant records, percent baseplate seating, and operative duration. Survivorship was compared among primary stilted-RSA (n=41), bone graft-RSA (n=42), and non-stilted/non-bone grafted RSA (n=1,032) within our institutional shoulder arthroplasty database. A radiographic examination of baseplate failure was also conducted across the study groups. Postoperative functional outcomes were compared in a matched analysis involving patients with a minimum 2-year follow-up between stilted patients and a non-stilted/non-bone grafted control group for primary RSA. RESULTS: All Stilted-RSA cases utilized metal augments and demonstrated a mean baseplate seating of 61% (range 45-75%). For stilted RSAs, survivorship was 100% and 92.6% at 2- and 5-years, compared to 98.3% and 94.6% for non-stilted/non-bone grafted and 96.3% and 79.5% for bone-grafted RSAs (p=0.042). At 5-years, the baseplate-related failure rates were greater in the stilted (7.4%) and the bone-grafted (9.3%) cohorts compared with the non-stilted/non-bone grafted cohort (1.1%, p<0.001). The mean time to baseplate failure was 30 months for stilted RSA. Functional outcomes for primary RSA were statistically similar between stilted and non-stilted patients, including range of motion, Constant, ASES, SST, UCLA, and SPADI scores. CONCLUSION: The stilted-RSA cohort exhibited noninferior revision and baseplate failure rates to that of bone-grafted RSA. This suggests that stilting may be a viable technique for patients undergoing primary RSA with significant glenoid deformity.

The effect of socioeconomic status on clinical outcomes and implant survivorship after primary anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total shoulder arthroplasty (TSA). METHODS: A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and preoperative to postoperative improvement in range of motion (ROM), shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) and revision-free survivorship were compared between groups. RESULTS: A total of 1148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 ± 8.2 and 69.9 ± 8.0 years, respectively, were included. The mean follow-up was 6.3 ± 3.6 years for anatomic and 4.9 ± 2.7 years for reverse total shoulder arthroplasty. We identified a weak negative correlation between national ADI and most functional outcome scores and ROM preoperatively (R range 0.07-0.16), postoperatively (R range 0.09-0.14), and preoperative to postoperative improvement (R range 0.01-0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes, and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic total shoulder arthroplasty cohort. However, in the reverse total shoulder arthroplasty cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between ADI groups. CONCLUSIONS: We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and ROM; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas.

Radial Tunnel Syndrome in a Collegiate Baseball Pitcher: A Case Report.

A Division I baseball pitcher presented with chronic forearm pain in his throwing arm while pitching. Physical examination was remarkable for point tenderness over the radial tunnel. A postexertion magnetic resonance imaging (MRI) scan revealed edema around the posterior interosseous nerve. The patient underwent decompression of the nerve along with radial tunnel release, which resulted in full resolution of symptoms and return to full baseball activities. Radial tunnel syndrome is a rare phenomenon but can occur in throwing athletes. MRI immediately after a pitching session aided in accurate diagnosis and successful surgical management.

Comparison of Pain Scores and Functional Outcomes of Patients Undergoing Arthroscopic Hip Labral Repair and Concomitant Capsular Repair or Plication Versus No Closure.

Background: The need for capsular closure during arthroscopic hip labral repair is debated. Purpose: To compare pain and functional outcomes in patients undergoing arthroscopic hip labral repair with concomitant repair or plication of the capsule versus no closure. Study Design: Cohort study. Methods: Outcomes were compared between patients undergoing arthroscopic hip labral repair with concomitant repair or plication of the capsule versus no closure at up to 2 years postoperatively and with stratification by age and sex. Patients with lateral center-edge angle <20°, a history of instability, a history of prior arthroscopic surgery in the ipsilateral hip, or a history of labral debridement only were excluded. Subanalysis was performed between patients undergoing no capsular closure who were propensity score matched 1:1 with patients undergoing repair or plication based on age, sex, and preoperative Modified Harris Hip Score (MHHS). We compared patients who underwent T-capsulotomy with concomitant capsular closure matched 1:5 with patients who underwent an interportal capsulotomy with concomitant capsular repair based on age, sex, and preoperative MHHS. Results: Patients undergoing capsular closure (n = 1069), compared with the no-closure group (n = 230), were more often female (68.6% vs 53.0%, respectively; P < .001), were younger (36.4 ± 13.3 vs 47.9 ± 14.7 years; P < .001), and had superior MHHS scores at 2 years postoperatively (85.8 ± 14.5 vs 81.8 ± 18.4, respectively; P = .020). In the matched analysis, no difference was found in outcome measures between patients in the capsular closure group (n = 215) and the no-closure group (n = 215) at any follow-up timepoint. No significant difference was seen between the 2 closure techniques at any follow-up timepoint. Patients with closure of the capsule achieved the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the 1-year MHHS at a similar rate as those without closure (MCID, 50.3% vs 44.9%, P = .288; PASS, 56.8% vs 51.1%, P = .287, respectively). Patients with T-capsulotomy achieved the MCID and the PASS for the 1-year MHHS at a similar rate compared with those with interportal capsulotomy (MCID, 50.1% vs 44.9%, P = .531; PASS, 65.7% vs 61.2%, P = .518, respectively). Conclusion: When sex, age, and preoperative MHHS were controlled, capsular closure and no capsular closure after arthroscopic hip labral repair were associated with similar pain and functional outcomes for patients up to 2 years postoperatively.

UCL Throwing Injuries in Nonprofessional Baseball Players: A 14-Year Retrospective Study.

BACKGROUND: This study evaluated treatment modality (surgical vs nonoperative) of medial ulnar collateral ligament (UCL) injuries in nonprofessional throwing baseball athletes by comparing type, severity, and location of UCL injury. HYPOTHESIS: Baseball players with closed medial epicondyle physes and concomitant throwing-related UCL injury will be more likely to undergo surgical intervention than players with open medial epicondyle physes. STUDY DESIGN: Retrospective. LEVEL OF EVIDENCE: Level 5. METHODS: A total of 119 baseball players with a mean age of 16.9 ± 2.5 years (range, 11-25 years) were included in the study. Datapoints included sex, age at time of injury, severity, and location of UCL injury, growth plate status, operative versus conservative management, and concomitant flexor forearm injury. RESULTS: A total of 75 players were treated conservatively; 43 underwent UCL reconstruction (UCL-R), and 1 had an unknown treatment outcome. No significant difference was found for age related to treatment type, UCL-R (17.2 ± 2.2) versus conservative treatment (16.8 ± 2.6). Athletes with closed medial epicondylar growth plates were more likely to undergo UCL-R than athletes with open medial epicondylar growth plates (P = 0.02). There were no significant differences between UCL injury location (42 distal, 37 proximal, 18 combined tear locations, 11 complete tears, and 11 intact UCLs with inflammation) by treatment type (P = 0.09). There was a significant difference for UCL severity (11 complete tears, 96 partial tears) by treatment type (P = 0.03). CONCLUSION: Nonprofessional athletes with closed medial epicondylar growth plates and throwing-related UCL injuries were more likely to be treated surgically. Baseball athletes with partial tears, if skeletally immature, require further long-term evaluation. CLINICAL RELEVANCE: Continued knowledge gains in this area of throwing medicine will further improve our treatment algorithms in nonprofessional baseball players.

Pain scores and functional outcomes of patients with shoulder labral repair using all-suture anchors versus conventional anchors.

HYPOTHESIS/PURPOSE: The purpose of this study was to compare PROMs in patients undergoing anterior glenoid labral repair using all-suture versus conventional anchors. We hypothesized PROMs would be similar between groups. METHODS: We performed a retrospective review of the Arthrex Global Surgical Outcomes System (SOS) database, querying patients who underwent arthroscopic glenoid labral repair between 01/01/2015 and 12/31/2020. Patients aged 18-100, who had isolated glenoid labrum repair with at least 12-month follow-up were included. The visual analog pain scale (VAS), Western Ontario Shoulder Instability Index, Veteran's RAND 12-items health survey, single assessment numeric evaluation and the American Shoulder and Elbow Surgeons score (ASES) were compared preoperatively, 3 months, 6 months, 1 year and 2 years postoperatively in patients who received all-suture anchors versus conventional anchors in the setting of anterior glenoid labrum repair. Our primary aim was comparison of PROMs between patients receiving all-suture versus conventional suture anchors. Secondarily, a sub-analysis was performed comparing outcomes based on anchor utilization for patients with noted anterior instability. RESULTS: We evaluated 566 patients, 54 patients receiving all-suture anchors and 512 patients receiving conventional anchors. At two-year follow-up there was no significant difference between the two groups in PROMs. In a sub-analysis of isolated anterior labrum repair, there was an improvement in ASES (P = 0.034) and VAS (P = 0.039) with the all-suture anchor at two-year follow-up. CONCLUSIONS: All-suture anchors provide similar or superior pain and functional outcome scores up to 2 years postoperatively compared to conventional anchors. CLINICAL RELEVANCE: As all-suture anchors gain popularity among surgeons, this is the largest scale study to date validating their use in the setting of glenoid labrum repair. Institutional Review Board (IRB): IRB202102550.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND: Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. METHODS: We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. RESULTS: Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA. CONCLUSIONS: Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Anatomic versus reverse total shoulder arthroplasty outcomes after prior contralateral anatomic total shoulder arthroplasty in patients with bilateral primary osteoarthritis with an intact rotator cuff.

PURPOSE: We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population. METHODS: A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups. CONCLUSION: Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA.

Quantifying success after first revision reverse total shoulder arthroplasty: the minimal and substantial clinically important percentage of maximal possible improvement.

BACKGROUND: When patients require reoperation after primary shoulder arthroplasty, revision reverse total shoulder arthroplasty (rTSA) is most commonly performed. However, defining clinically important improvement in these patients is challenging because benchmarks have not been previously defined. Furthermore, although the minimal clinically important difference and substantial clinical benefit are commonly used to assess clinically relevant success, these metrics are limited by ceiling effects that may cause inaccurate estimates of patient success. Our purpose was to define the minimal and substantial clinically important percentage of maximal possible improvement (MCI-%MPI and SCI-%MPI) for commonly used pain and functional outcome scores after revision rTSA and to quantify the proportion of patients achieving clinically relevant success. METHODS: This retrospective cohort study used a prospectively collected single-institution database of patients who underwent first revision rTSA between August 2015 and December 2019. Patients with a diagnosis of periprosthetic fracture or infection were excluded. Outcome scores included the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California, Los Angeles (UCLA) scores. We used an anchor-based method to calculate the MCI-%MPI and SCI-%MPI. In addition, we calculated the MCI-%MPI using a distribution-based method for historical comparison. The proportions of patients achieving each threshold were assessed. The influence of sex, type of primary shoulder arthroplasty, and reason for revision rTSA were also assessed by calculating cohort-specific thresholds. RESULTS: Ninety-three revision rTSAs with minimum 2-year follow-up were evaluated. The mean age of the patients was 67 years; 56% were female, and the average follow-up was 54 months. Revision rTSA was performed most commonly for failed anatomic TSA (n = 47), followed by hemiarthroplasty (n = 21), rTSA (n = 15), and humeral head resurfacing (n = 10). The indication for revision rTSA was most commonly glenoid loosening (n = 24), followed by rotator cuff failure (n = 23) and subluxation and unexplained pain (n = 11 for both). The anchor-based MCI-%MPI thresholds (% of patients achieving) were ASES = 33% (49%), raw Constant = 23% (64%), normalized Constant = 30% (61%), UCLA = 51% (53%), SST = 26% (68%), and SPADI = 29% (58%). The anchor-based SCI-%MPI thresholds (% of patients achieving) were ASES = 55% (31%), raw Constant = 41% (27%), normalized Constant = 52% (22%), UCLA = 66% (37%), SST = 74% (25%), and SPADI = 49% (34%). CONCLUSIONS: This study is the first to establish thresholds for the MCI-%MPI and SCI-%MPI at minimum 2 years after revision rTSA, providing physicians an evidence-based method to assess patient outcomes postoperatively.

Does hydrogen peroxide application to the dermis following surgical incision affect Cutibacterium acnes cultures in total shoulder arthroplasty in male patients? A randomized controlled trial.

BACKGROUND: Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H2O2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H2O2 directly to the dermis following skin incision would further decrease deep culture positivity rates. METHODS: We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H2O2, ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H2O2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors. RESULTS: Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P = .600) and final (61% vs. 50%, P > .999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P = .130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P = .048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P = .023). There were no wound complications in either cohort. CONCLUSIONS: An additional H2O2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H2O2 to decrease C acnes contamination.

Preseason lower extremity range of motion, flexibility, and strength in relation to in-season injuries in NCAA division I gymnasts.

OBJECTIVES: To determine if preseason lower extremity ROM, flexibility, and strength differ in collegiate gymnasts (NCAA Division 1) who do or do not sustain an injury during the competitive season. METHODS: Over four seasons, a total of 15 female gymnasts (age = 20.5 ± 1.0 years) underwent preseason screening (30 gymnast-season). We tested joint ROM (hip: flexion, internal and external rotation; ankle: weightbearing dorsiflexion), muscle flexibility (passive straight leg raise, Thomas,' Ober's, Ely's tests) and strength (hip extensors, abductors, and flexors isometric strength via a handheld dynamometer; knee: quadriceps and hamstring isokinetic strength at 60°/sec). The team athletic trainer tracked overuse lower extremity injuries (restricted gymnasts from full participation, occurred as from participation in organized practice or competition, and required medical attention) during each season. For athletes that tested multiple seasons, each encounter was considered independent, and each preseason assessment was linked to overuse injuries sustained during the same competitive season. Gymnasts were dichotomized into injured and non-injured groups. An independent t-test was used to measure differences in preseason outcomes between injured and non-injured groups. RESULTS: During four years, we recorded 23 overuse lower extremity injuries. Gymnasts that sustained an in-season overuse injury demonstrated significantly lower hip flexion ROM (mean difference: -10.6°; 95% confidence interval: -16.5, -4.6; p < 0.01) and lower hip abduction strength (mean difference: -4.7% of body weight; 95% confidence interval: -9.2, -0.3; p = 0.04). CONCLUSION: Gymnasts who sustain an in-season overuse lower extremity injury have significant preseason deficit of hip flexion ROM and weakness in the hip abductors. These findings indicate potential impairments in the kinematic & kinetic chains responsible for skill performance and energy absorption during landing.

Relationship between the prosthesis scapular neck angle and clinical outcomes in reverse shoulder arthroplasty.

Background: Optimal glenosphere positioning in reverse shoulder arthroplasty (RSA) remains highly debated. We aimed to characterize the association between the prosthesis scapular neck angle (PSNA) and postoperative range of motion (ROM) and clinical outcome scores. Methods: A retrospective review of 284 RSAs using a single design with minimum 2-year follow-up was performed. Glenosphere tilt was measured postoperatively using PSNA. ROM and functional outcome scores were assessed preoperatively and at latest follow-up. The PSNA was dichotomized to inferior or superior groups (>90° vs ≤ 90°, respectively) and stratified into quartiles; ROM and outcome score measures were compared between groups controlling for inferior glenosphere overhang. Results: No range of PSNA was consistently associated with superior ROM, clinical outcome scores, or rates of complications including scapular notching. However, greater preoperative to postoperative improvement in active FE was found for superiorly (PSNA ≤ 90°) versus inferiorly tilted glenospheres (37° ± 33° vs 53° ± 35°, P = 0.005) and the greater improvement in active FE (57° ± 35°, P = 0.004) was further isolated to the first quartile (mean 85.1° ± 3.5°). Discussion: A lack of variation in clinical outcomes based on PSNA suggests negligible short-term (median follow-up 3.1 years) clinical significance when glenosphere tilt falls within the distribution of this cohort (mean 92.6° ± 6.2°).

Early outcomes after first reverse total shoulder arthroplasty better prognosticate contralateral success compared with early outcomes after anatomic total shoulder arthroplasty.

BACKGROUND: The ideal timing between bilateral total shoulder arthroplasty (TSA) is unclear. The purpose of this study is to determine whether early outcomes after first TSA can be used to predict clinical outcomes after TSA of the contralateral shoulder and to evaluate the ideal time after TSA to perform the contralateral shoulder. METHODS: A single-institution prospectively collected shoulder arthroplasty database was reviewed. Patients who underwent bilateral primary anatomic or reverse TSA (aTSA + rTSA) without an indication of fracture, tumor, or infection were identified. Included patients had minimum 2-year follow-up on their second TSA and postoperative follow-up after their first TSA at 3 months, 6 months, 1 year, or 2 years. Our primary outcome was whether outcome scores and motion at 3-month, 6-month, 1-year, and 2-year follow-up after first TSA predicted clinical success after second TSA at final follow-up, defined as achieving the patient acceptable symptomatic state (PASS = the highest level of symptoms beyond which patients consider themselves well). Outcomes included the American Shoulder and Elbow Surgeons and Constant scores, abduction, forward elevation, and external/internal-rotation. Multivariable logistic regression determined whether postoperative outcomes after first TSA were predictive of achieving the PASS after second TSA independent of age, sex, and body mass index. Receiver operating characteristic analysis determined cutoffs of postoperative outcomes after first TSA at each time point that best predicted achieving the prosthesis-specific PASS after second TSA. RESULTS: One hundred thirty-four patients were included in the final analysis (110 aTSA and 158 rTSA). Range of motion and outcome scores at late (1- or 2-year) follow-up after first aTSA were more predictive of achieving the second TSA PASS compared with early (3- or 6-month) outcomes. In contrast, outcomes after early and late follow-up after first rTSA were similarly predictive of achieving the second TSA PASS. Specifically, the Constant score threshold at 2 years after first aTSA (79.4; area under the curve [AUC] = 0.804) better differentiated achieving the second TSA PASS vs. the 6-month threshold (72.0; AUC = 0.600). In contrast, the Constant score threshold at 2 years after first rTSA (76.4; AUC = 0.703) was similarly discriminant of achieving the second TSA PASS compared with the 6-month threshold (65.8; AUC = 0.711). CONCLUSIONS: Patients with good outcomes after first rTSA can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. In contrast, success after first aTSA does not reliably predict contralateral success until ≥1 year.

Staged Repair of Simultaneous Bilateral Proximal Hamstring Rupture and 2 Year Outcome: A Case Report.

CASE: A 53-year-old man presented with simultaneous, bilateral proximal hamstring ruptures. He underwent open, staged surgical repair of the proximal hamstrings, followed by a modified course of rehabilitation. At 2-year follow-up, the patient reports excellent outcomes. CONCLUSION: Simultaneous, bilateral, 3-tendon rupture of the proximal hamstrings is a rare lower extremity injury. Surgical treatment of such injuries presents several unique challenges. Staged surgical repair is an effective treatment option.