Artificial Intelligence Machine Learning Algorithms Versus Standard Linear Demographic Analysis in Predicting Implant Size of Anatomic and Reverse Total Shoulder Arthroplasty.

BACKGROUND: Accurate and precise templating is paramount for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) to enhance preoperative planning, streamline surgery, and improve implant positioning. We aimed to evaluate the predictive potential of readily available patient demographic data in TSA and RSA implant sizing, independent of implant design. METHODS: A total of 578 consecutive, primary, noncemented shoulder arthroplasty cases were retrospectively reviewed. Demographic variables and implant characteristics were recorded. Multivariate linear regressions were conducted to predict implant sizes using patient demographic variables. RESULTS: Linear models accurately predict TSA implant sizes within 2 millimeters of humerus stem sizes 75.3% of the time, head diameter 82.1%, head height 82.1%, and RSA glenosphere diameter 77.6% of the time. Linear models predict glenoid implant sizes accurately 68.2% and polyethylene thickness 76.6% of the time and within one size 100% and 95.7% of the time, respectively. CONCLUSION: Linear models accurately predict shoulder arthroplasty implant sizes from demographic data. No significant statistical differences were observed between linear models and machine learning algorithms, although the analysis was underpowered. Future sufficiently powered studies are required for more robust assessment of machine learning models in predicting primary shoulder arthroplasty implant sizes based on patient demographics.

Bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow: an evaluation of long-term outcomes.

BACKGROUND: Ulnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen. METHODS: A retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of 3 fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, HO prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Score, and visual analog scale pain scores. RESULTS: Thirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative vs. long-term postoperative elbow extension (P < .001), flexion (P < .001), and total arc of motion (P < .001). There was a statistically significant improvement in pre- vs. postprocedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2-0.7; P = .002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical comorbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97° and average Mayo Elbow Performance Score of 80 ("good") at long-term follow-up. CONCLUSIONS: The combination of operative management, postoperative HO prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes.

The impact of modern airport security protocols on patients with total shoulder replacements.

BACKGROUND: Advancements in airport screening measures in response to 9/11 have resulted in increased false alarm rates for patients with orthopedic and metal implants. With the implementation of millimeter-wave scanning technology, it is important to assess the changes in airport screening experiences of patients who underwent total shoulder arthroplasty (TSA). METHODS: Here, 197 patients with prior anatomic and reverse TSA completed between 2013 and 2020 responded to a questionnaire regarding their experiences with airport travel screening after their operation. Of these patients, 86 (44%) stated that they had traveled by plane, while 111 (56%) had not. The questionnaire addressed several measures including the number of domestic and international flights following the operation, number of false alarm screenings by the millimeter-wave scanner, patient body habitus, and presence of additional metal implants. RESULTS: A total of 53 patients (62%) responded "yes" to false screening alarms due to shoulder arthroplasty. The odds of a false screening alarm for patients with other metal implants was 5.87 times that of a false screening alarm for patients with no other metal implants (P<0.1). Of a reported 662 flights, 303 (45.8%) resulted in false screening alarms. Greater body mass index was not significantly lower in patients who experienced false screening alarms (P=0.30). CONCLUSIONS: Patients with anatomic and reverse TSA trigger false alarms with millimeter-wave scanners during airport screening at rates consistent with prior reports following 9/11. Patient education on the possibility of false alarms during airport screening is important until improvements in implant identification are made. Level of evidence: IV.

Outcomes of Total Knee and Hip Arthroplasty in Patients With Perioperative Thrombocytopenia.

BACKGROUND: Thrombocytopenia is an abnormally low level of blood platelets (less than 150,000/mL) resulting in an increased risk for bleeding. Typically, patients with platelet levels below 50,000/mL should delay arthroplasty or be transfused with platelets before surgery. However, existing studies are mixed regarding the effects of more moderate thrombocytopenia in terms of total knee and hip arthroplasty outcomes. METHODS: This level III retrospective chart review examined the effects of different severities of preoperative thrombocytopenia on length of hospitalization, readmission, and transfusion rates in 5,617 primary total knee and hip arthroplasties at one tertiary academic medical center. Preoperative platelet levels were sectioned into clinically relevant groups and compared with clinical outcomes using univariable and multivariable models. RESULTS: On univariate analysis, having platelet levels of <100,000/mL and 100 to 149,000/mL was associated with a longer length of stay. However, after controlling individual demographics, there was no association between platelet levels and length of stay, nor with 30-day readmission. Finally, on univariate analysis, patients with platelet levels of <100,000/mL and 100 to 149,000/mL were more likely to have a blood transfusion, which remained true for those with <100,000/mL after controlling for individual demographics. CONCLUSIONS: Total hip and total knee arthroplasty are safe in patients with varying platelet levels and not associated with increased length of stay or 30-day readmission. However, patients with more severe thrombocytopenia are more likely to receive red blood cell transfusions than patients with milder thrombocytopenia.

Core decompression for early-stage avascular necrosis of the humeral head: current concepts and techniques.

Avascular necrosis (AVN) of the humeral head is a rare, yet detrimental complication. Left untreated, humeral head AVN frequently progresses to subchondral fracturing and articular collapse. Cases of late-stage humeral head AVN commonly require invasive procedures including humeral head resurfacing, hemiarthroplasty, and total shoulder arthroplasty (TSA) to improve clinical outcomes. However, in cases of early-stage AVN, core decompression of the humeral head is a viable and efficacious short-term treatment option for patients with pre-collapse AVN of the humeral head to improve clinical outcomes and prevent disease progression. Several techniques have been described, however, a percutaneous, arthroscopic-assisted technique may allow for accurate staging and concomitant treatment of intraarticular pathology during surgery, although further long-term clinical studies are necessary to assess its overall outcomes compared with standard techniques. Biologic adjunctive treatments, including synthetic bone grafting, autologous mesenchymal stem cell/bone marrow grafts, and bone allografts are viable options for reducing the progression of AVN to further collapse in the short term, although long-term follow-up with sufficient study power is lacking in current clinical studies. Further long-term outcome studies are required to determine the longevity of core decompression as a conservative measure for early-stage AVN of the humeral head.

Bubble Sign: An Arthroscopic Technical Trick to Differentiate Between Partial- and Full-Thickness Rotator Cuff Tears.

Distinguishing between partial-thickness and small focal full-thickness tears of rotator cuff may be important for determining the appropriate surgical treatment options and repair constructs in the care of patients with rotator cuff pathology. This article presents a simple intraoperative technical trick to aid in identification of small full-thickness tears of the superior rotator cuff. The relatively higher-pressured subacromial space and the low-pressured glenohumeral joint are separated by the supraspinatus tendon. When this barrier is compromised due to a full-thickness tear, free fluid flows from high to low pressure down the native pressure gradient. This is seen as the movement of air bubbles into the glenohumeral joint from the subacromial space and can be used to identify the presence of a full-thickness rotator cuff tear on diagnostic arthroscopy.

Single-Center Results of Colorectal Procedures Performed with Fully Articulated Laparoscopic Artisential® Devices.

INTRODUCTION: The ArtiSential® line of products from LivsMed (Seongnam, Republic of Korea) are fully articulated hand-held laparoscopic instruments, possessing end-effectors that closely imitate those of surgical robots with regard to shape and dexterity. Feasibility and safety studies describing the initial experiences with these devices in upper and lower gastrointestinal as well as thoracic surgery have been published. This report presents the outcomes of the largest cohort to date of colorectal procedures performed with Artisential® instruments in a single center. MATERIALS AND METHODS: Between September 2020 and May 2022, prospective data were collected from patients undergoing ArtiSential®-assisted laparoscopic surgery. A retrospective data analysis was performed for all patients who underwent ArtiSential®-assisted surgery for colorectal indication. Indications for colorectal surgery included rectal and colon cancer, complicated diverticular disease, inflammatory bowel disease, obstructed defecation syndrome, endoscopically nonresectable adenomas and chronic anastomotic fistula following a low anterior resection (LAR). RESULTS: A total of 73 patients (49 males, 24 females) underwent Artisential®-assisted colorectal surgery. The median age of the patients was 62 years (range 34-88) and the median body mass index (BMI) was 27 kg/m2 (range 19-51). Indications for surgery were colorectal malignancy (n=55, 75%), complicated diverticular disease (n=11, 15%), obstructed defecation syndrome (n=3, 4.1%), inflammatory bowel disease (n=2, 2.7%), endoscopically nonresectable adenomas (n=1, 1.4%) and chronic anastomotic fistula following LAR (n=1, 1.4%). The median operative time was 240 minutes (range 95-458). There were no conversions to standard straight-stick laparoscopy or to laparotomy, and no intraoperative complications. All patients who were operated upon for colorectal malignancy had an adequate oncological resection (R0=100%). The median length of stay was 7 days (range 3-36). The overall complication rate was 10.9 % (Clavien-Dindo II: 1 patient, Clavien-Dindo IIIb: 7 patients). There were two readmissions, one unrelated, and no mortalities. CONCLUSIONS: This larger series confirms the results of previous reports on the safety and feasibility of Artisential® use in complex laparoscopic colorectal surgery. To examine potential benefits in outcome, comparative studies involving Artisential®, robotic-assisted and standard laparoscopic surgery are needed.

Technical Pearls for Arthroscopic Labral Augmentation of the Hip.

Our recent understanding of the importance of the acetabular labral suction seal has placed preserving labral integrity as a guiding principle in hip preservation surgery. In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction. At this time, there are few studies that have described the technical pearls of performing labral augmentation of the hip. In this technique guide, we describe, in detail, the kite technique for the introduction, control, and acetabular fixation of a hip labral augmentation graft. Comparable to flying a kite with 2 fly lines and to the previously described kite technique for hip labral reconstruction, the kite technique for labral augmentation is based on the principle that the use of 2 control sutures in a pulley system creates an efficient method to accurately and reproducibly facilitate graft passage and fixation during arthroscopic labral augmentation procedures.

Capsular Reconstruction of the Hip Using Modified Kite Technique: A Technical Guide for Efficient Graft Management and Fixation.

Preserving capsular integrity has become an important principle of hip preservation surgery given the increasingly recognized deleterious effects of instability in cases of capsular insufficiency. When capsular tissue is deficient, capsular reconstruction may be indicated to restore function of the iliofemoral ligament and improve hip biomechanics. To date, few studies have presented technical guidance on performing arthroscopic capsular reconstruction of the hip. In this Technical Note, we introduce a modified kite technique for arthroscopic entry, control, and fixation of a capsular reconstruction graft. Similar to flying a kite with multiple fly lines, and to the previously described kite technique for hip labral reconstruction, the principles of this method are founded on the belief that control sutures within a pulley system facilitate safe and efficient graft management during capsular reconstruction procedures.

Superior Capsule Reconstruction for Irreparable Massive Rotator Cuff Tears: Does It Make Sense? A Systematic Review of Early Clinical Evidence.

BACKGROUND: Treatment of irreparable massive rotator cuff tears (MRCTs) in patients without advanced glenohumeral osteoarthritis remains a challenge. Arthroscopic superior capsule reconstruction (SCR) represents a newer method for treatment with increasing popularity and acceptance. PURPOSE: To analyze the clinical evidence surrounding SCR and determine the current clinical outcomes postoperatively. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. The study quality was evaluated according to the Modified Coleman Methodology Score. Studies in English evaluating SCR outcomes were included. RESULTS: Seven studies were reviewed, including 352 patients (358 shoulders) treated with arthroscopic SCR with the mean duration of follow-up ranging from 15 to 48 months (range, 12-88 months). Fourteen patients were lost to follow-up, leaving 338 patients (344 shoulders) with clinical outcome data. Graft types included dermal allografts (n = 3 studies), fascia lata autografts (n = 3), or both (n = 1). Most commonly, a double-row technique was utilized for humeral graft fixation. The most common complication included graft tears in 13% of patients, resulting in 15 SCR revisions and 7 reverse shoulder arthroplasties. Postoperatively, improvements in visual analog scale (2.5 to 5.9), American Shoulder and Elbow Surgeons (20 to 56), Japanese Orthopaedic Association (38.0), Subjective Shoulder Value (37.0 to 41.3), and Constant (11.6 to 47.4) scores were observed. Three studies reported respective satisfaction rates of 72.9%, 85.7% and 90%. Increases in external rotation, internal rotation, and abduction with improved strength in external rotation were observed postoperatively. Improvement of pseudoparalysis was also observed in 3 studies. One study reported return to sports in 100% of patients (2 competitively, 24 recreationally) with no adverse outcomes. CONCLUSION: SCR showed good to excellent short-term clinical outcomes with adequate pain relief and functional improvement. The current evidence suggests that the procedure is an alternative for symptomatic patients with irreparable MRCT; however, the included studies were fair to poor in quality, and there were some notable complications. Long-term follow-up will determine the longevity and ultimate role of this new method in the treatment of irreparable MRCT.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Successful Hip Arthroscopy Using Postless Distraction in a Professional Basketball Player: A Case Report.

CASE: A 36-year-old 7'0' male professional basketball player presented with hip pain and radiographic imaging consistent with femoroacetabular impingement syndrome and a labral tear. Hip arthroscopy was performed with the patient positioned supine on a postless distraction table to negate the risk of pudendal nerve and perineal skin complications. Hip distraction was achieved with only 40 lbs (18.14 kg) of distraction force. Labral repair and cam osteochondroplasty were safely performed without complication. CONCLUSIONS: This case is the first to demonstrate that postless distraction may be considered for patients at end ranges of height that exceed the limitations of common hip arthroscopy tables.

Robotic Inguinal Hernia Repair (TAPP) First Experience with the New Senhance Robotic System.

INTRODUCTION: This retrospective study was performed to evaluate the safety and feasibility of the new Senhance Robotic System (TransEnterix Inc., Morrisville, North Carolina) for inguinal hernia repairs using the transabdominal preperitoneal approach. MATERIALS AND METHODS: From March to September 2017, 76 inguinal hernia repairs in 64 patients were performed using the Senhance Robotic System. Patients were between 18 and 90 years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life expectancy of less than 12 months, and a body mass index (BMI) < 35. A retrospective chart review was performed for a variety of pre-, peri-, and postoperative data including, but not limited to, patient demographics, hernia characteristics, and intraoperative and postoperative complications. RESULTS: Fifty-four male and 10 female patients were included in the study. Median age was 56.5 years (range 22-86 years), and median BMI was 25.9 kg/m2 (range 19.5-31.8 kg/m2). Median docking time was seven minutes (range 2-21 minutes), and median operative time was 48 minutes (range 18-142 minutes). Two cases were converted to standard laparoscopic surgery due to robot malfunction and abdominal wall bleeding, respectively. Median length of stay was one day. CONCLUSION: We report the first series of laparoscopic inguinal hernia repairs using the new Senhance Robotic System. Compared to conventional laparoscopic transabdominal preperitoneal (TAPP) hernia repairs, there was no significant difference in operative time or perioperative complications. Additionally, there was no significant learning curve detected due to its intuitive applicability. Therefore, the Senhance Robotic System promises broad applicability across a range of laparoscopic general surgical operations.

Identification of a secreted fatty acid and retinol-binding protein (Hp-FAR-1) from Heligmosomoides polygyrus.

Hp-FAR-1 is a major, secreted antigen of the parasitic nematode Heligmosomoides polygyrus, a laboratory mouse model frequently used to study the cellular mechanisms of chronic helminth infections. The DNA encoding Hp-FAR-1 was recovered by screening a fourth larval (L4) H. polygyrus cDNA expression library using antibodies raised against L4 stage excretory/secretory (E/S) proteins. Predictions of secondary structure based on the Hp-FAR-1 amino acid sequence indicated that an alpha-helix predominates in Hp-FAR-1, possibly with some coiled-coil conformation, with no beta-structure. Fluorescence-based ligand binding analysis confirmed that the recombinant Hp-FAR-1 (rHp-FAR-1) binds the fluorescent fatty acid analog 11-((5-[dimethylaminoaphthalene-1-sulfonyl)amino)undecanoic acid (DAUDA), and by competition oleic acid. RT-PCR amplification of the hp-far-1 gene indicated that the gene is transcribed in all parasitic stages of the organism's life cycle. The presence of a secreted FAR protein in the well-defined laboratory model of H. polygyrus provides an excellent model for the further study and analysis of the in vivo role of secreted FAR proteins in parasitism, and supports the mounting evidence that secreted FAR proteins play a major role in nematode parasitism.