Anatomic factors associated with degeneration and fraying of the coracoacromial ligament.

BACKGROUND: The coracoacromial ligament (CAL) is frequently observed to be damaged during arthroscopy and it is unclear how demographic, anatomic, and radiographic factors are related to CAL degeneration in full-thickness rotator cuff tears. METHODS: A prospective study was conducted of patients at a single institution undergoing shoulder arthroscopy for first-time, full-thickness rotator cuff tears. We evaluated preoperative anteroposterior radiographs to obtain critical shoulder angle, glenoid inclination, acromial index, acromiohumeral distance, lateral acromial angle, and acromial morphology. We documented CAL quality, rotator cuff tear size and pattern during arthroscopy. Multiple logistic regression was used to identify predictive factors for encountering severe CAL fraying during arthroscopy. RESULTS: Shoulders had mild CAL degeneration in 58.1% of cases, whereas severe CAL degeneration was present in 41.9% of shoulders. Patients with severe CAL attrition were significantly older (62.0 years vs. 58.0 years, P=0.042). Shoulders with severe CAL attrition had large rotator cuff tears in 54.1% of cases (P<0.001), and tears involving the infraspinatus (63.2% vs. 29.6%, P=0.003). The severe degeneration group was more likely to have a larger critical shoulder angle measurement on preoperative radiographs than those in the mild attrition group (36.1°±3.6° [range, 30°-45°] vs. 34.1°±3.8° [range, 26°-45°], P=0.037). CONCLUSIONS: While the clinical impact of CAL degeneration remains uncertain, increased severity of CAL degeneration is associated with older age, larger rotator cuff tear size, presence of infraspinatus tearing, and increased preoperative critical shoulder angle. Level of evidence: III.

Short-Term Results of a Convertible Diaphyseal-fit Anatomic Shoulder Arthroplasty System.

Objectives: The purpose of this analysis is to present a two-year follow-up of patient-reported outcomes, revision rate, and notable radiographic features of a convertible, diaphyseal-fit anatomic total shoulder arthroplasty system (ATSA). Methods: From June 2012 to June 2015, 100 shoulders were treated with ATSA using a convertible, diaphyseal-fit stem. Functional outcomes and radiographic findings were assessed preoperatively and at 6 months, 1 year, and 2 years postoperatively. Complications and reoperations were also determined. Results: Ninety-three shoulders were analyzed in this study. Patients were 47.3% male and had an average age of 67.3±8.1-years-old (range 44.7-89.1). Two-year clinical outcomes show a revision rate of 4.3%. Average pre-operative ASES was 37.1±18.9 (6.7-86.7), SST (77.4%) was 3.1±2.4 yes responses (0-9), and SANE (88.2) was 25.4±21.5% (0-85.0%). At two years post-operative average (75% follow-up) ASES was 89.3±15.1 (37.0-100), SST was 10.0±2.5 yes responses (0-12), and SANE was 85.6%±17.0% (33.0-100%). Radiographic analysis at two years identified 2 shoulders (4%) with glenoid radiolucency (both Lazarus grade 1), 5 shoulders with at least one humeral radiolucent line (10%), and 9 shoulders (18%) with stress-shielding. There were 12 shoulders (24%) with distal pedestal formation. This finding was associated with the presence of radiolucent lines (P=0.002). Conclusion: This two-year analysis identified improvement in ASES, SST, and SANE scores and a low revision rate. resence of a distal pedestal was associated with increased rates of radiolucent lines. Further analysis with longer-term and more robust follow-up will improve our understanding of the risks and benefits of this shoulder system.

Profibrotic behavior of fibroblasts derived from patients that develop posttraumatic shoulder stiffness.

Background and Aims: Arthrofibrosis is a severe scarring condition characterized by joint stiffness and pain. Fundamental to developing arthrofibrotic scars is the accelerated production of procollagen I, a precursor of collagen I molecules that form fibrotic deposits in affected joints. The procollagen I production mechanism comprises numerous elements, including enzymes, protein chaperones, and growth factors. This study aimed to elucidate the differences in the production of vital elements of this mechanism in surgical patients who developed significant posttraumatic arthrofibrosis and those who did not. Methods: We studied a group of patients who underwent shoulder arthroscopic repair of the rotator cuff. Utilizing fibroblasts isolated from the patients' rotator intervals, we analyzed their responses to profibrotic stimulation with transforming growth factor ß1 (TGFß1). We compared TGFß1-dependent changes in the production of procollagen I. We studied auxiliary proteins, prolyl 4-hydroxylase (P4H), and heat shock protein 47 (HSP47), that control procollagen stability and folding. A group of other proteins involved in excessive scar formation, including connective tissue growth factor (CTGF), α smooth muscle actin (αSMA), and fibronectin, was also analyzed. Results: We observed robust TGFß1-dependent increases in the production of CTGF, HSP47, αSMA, procollagen I, and fibronectin in fibroblasts from both groups of patients. In contrast, TGFß1-dependent P4H production increased only in the stiff-shoulder-derived fibroblasts. Conclusion: Results suggest P4H may serve as an element of a mechanism that modulates the fibrotic response after rotator cuff injury.

Periprosthetic joint infections of the shoulder: A 10-year retrospective analysis outlining the heterogeneity among these patients.

Background: Diagnosis and treatment of shoulder periprosthetic joint infection is a difficult problem. The purpose of this study was to utilize the 2018 International Consensus Meeting definition of shoulder periprosthetic joint infection to categorize revision shoulder arthroplasty cases and determine variations in clinical presentation by presumed infection classification. Methods: Retrospective review of patients undergoing revision shoulder arthroplasty at a single institution. Likelihood of periprosthetic joint infection was determined based on International Consensus Meeting scoring. All patients classified as definitive or probable periprosthetic joint infection were classified as periprosthetic joint infection. All patients classified as possible or unlikely periprosthetic joint infection were classified as aseptic. The periprosthetic joint infection cohort was subsequently divided into culture-negative, non-virulent microorganism, and virulent microorganism cohorts based on culture results. Results: Four hundred and sixty cases of revision shoulder arthroplasty were reviewed. Eighty (17.4%) patients were diagnosed as definite or probable periprosthetic joint infection, of which 29 (36.3%), 39 (48.8%), and 12 (15.0%) were classified as virulent, non-virulent, or culture-negative periprosthetic joint infection, respectively. There were significant differences among periprosthetic joint infection subgroups with regard to preoperative C-reactive protein (p = 0.020), erythrocyte sedimentation rate (p = 0.051), sinus tract presence (p = 0.008), and intraoperative purulence (p < 0.001). The total International Consensus Meeting criteria scores were also significantly different between the periprosthetic joint infection cohorts (p < 0.001). Discussion: While the diagnosis of shoulder periprosthetic joint infection has improved with the advent of International Consensus Meeting criteria, there remain distinct differences between periprosthetic joint infection classifications that warrant further investigation to determine the accurate diagnosis and optimal treatment.

The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair. METHODS: This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance. RESULTS: There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery. CONCLUSION: The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.

Postoperative stiffness after reverse total shoulder arthroplasty.

Purpose: The purpose of this study was to evaluate the rate and risk factors for stiffness after reverse shoulder arthroplasty and the ramifications on the patient-reported outcomes. Method: A consecutive series of patients who underwent reverse shoulder arthroplasty were prospectively followed for one year. Passive range of motion was measured preoperatively and at regular intervals postoperatively. Patients with passive forward elevation of less than 100° or passive external rotation of less than 30° were defined as stiff. Radiographic parameters and postoperative patient-reported outcome scores were collected. Results: Seventy-six patients were available for review. The prevalence of postoperative stiffness following reverse shoulder arthroplasty was 47% at three months, 31% at six months, and 25% at one year. Preoperative shoulder stiffness was associated with three-month postoperative stiffness only. In patients with one-year stiffness, smaller (p = 0.03) and less lateralized glenospheres (p = 0.024) were more common. Stiffness was not associated with one-year patient-reported outcome scores. Conclusion: Stiffness is common after reverse shoulder arthroplasty and often improves at one-year after surgery. Implant design and selection may be important determinants of passive range of motion. While stiffness does not appear to influence patient-reported outcome scores, one of four patients will potentially have stiffness one year following reverse shoulder arthroplasty.Level of evidence: Level III; retrospective study.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

BACKGROUND: Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS: Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS: A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS: This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

Post-operative Urinary Dysfunction Following Shoulder Surgery: Rates and Risk Factors.

Background: Post-operative urinary retention (POUR) and dysfunction are recognized complications following orthopaedic surgery. Recent literature has focused on urinary retention and its associated complications following hip and knee reconstruction and lower extremity surgery. There is a paucity of literature focusing on POUR and shoulder surgery. The purpose of this study is to describe the rates of urinary dysfunction in patients undergoing shoulder surgery as well as the associated risk factors. Methods: This was a single institution, prospective cohort study. Eligibility criteria included patients older than 50 years of age undergoing open or arthroscopic shoulder surgery. The primary outcome was the American Urological Association (AUA) symptom score (7 questions total scored 0-5, total 35 points max) administered before and after surgery. Higher scores reflect worse urinary dysfunction. Intra-operative data such as type of surgery, type of anesthesia, use of anticholinergics, peripheral nerve block, length of case, and amount of intravenous fluids were collected. Results: Of 194 patients, the mean age was 61.4 years (Standard Deviation (S.D.) = 13.0)) and the average BMI was 29.2 (S.D. = 5.6). The sample was 35.6% female. Overall, 46.4% reported worse AUA scores post-operatively within the first 3 to 5 days, including 4.1% of which were clinically defined as "moderately worse" (>5 point worse) or "much worse" (>11 points worse). Worse preoperative AUA scores correlated with worse postop AUA score on linear regression analysis (r=0.883, P<0.0001). Males with a history of BPH showed a statistically significant positive association with worsening urinary dysfunction postoperatively (P=0.039). Four patients (2.1%) required postoperative catheterization. A significantly higher percentage of patients with preoperative AUA scores of ≥11 experienced worsening of urinary function post-operatively (P=0.04). Conclusion: Worsening of urinary function following shoulder surgery is common. The AUA score may be used to identify at-risk patients and to track changes in urinary function post-operatively. Men with a diagnosis of BPH are at particularly high risk. Further investigation is needed to elucidate the impact of urinary dysfunction on patient outcomes, satisfaction, and cost as well as the role of prophylactic medications.

Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs.

BACKGROUND: Primary rotator cuff repairs in complex cases (older patient age, larger tear sizes, chronic tears) and revision repairs are at high risk for failure of healing. PURPOSE: To examine clinical outcomes and healing rates in complex and revision rotator cuff repairs with dermal allograft augmentation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective study was made of cases performed by 3 fellowship-trained surgeons via a uniform technique involving rotator cuff repairs with allograft augmentation. In all cases, a 1.5-mm, human, decellularized dermal graft was tied on top of the tendon at the medial row and compressed to the rotator cuff footprint using a double-row technique. Postoperative magnetic resonance imaging (MRI) was performed at a minimum of 6 months and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and 12-Item Short Form Health Survey scores were collected at a minimum of 2 years postoperatively. RESULTS: A total of 35 patients (23 revision repairs, 12 primary complex repairs) were included. The mean patient age was 57.9 years (range, 41.0-70.5 years). All shoulders had 2-tendon tears (supraspinatus and infraspinatus), and 8 included the upper 50% of the subscapularis. At a minimum of 2 years after surgery (mean, 3.2 years), mean ASES and SANE scores improved from 42.4 and 35.3 to 77.6 and 73.5, respectively (P < .001). In the 23 patients (66%) with postoperative MRI evaluation, 11 (48%) had images showing the tendons were retorn. ASES (89.7 vs 66.4; P = .04) and SANE (84.1 vs 50.5; P = .02) scores were higher in healed patients than those with retears. The retear group had a higher degree of preoperative fatty atrophy of the infraspinatus (P = .024). CONCLUSION: Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. Approximately half of patients experienced a failure of healing, which was associated with poorer functional results.

Is D-dimer a Reliable Serum Marker for Shoulder Periprosthetic Joint Infection?

BACKGROUND: The diagnosis of periprosthetic shoulder infection continues to be difficult to make with confidence. Serum D-dimer has proven to be effective as a screening tool for periprosthetic joint infection in other major joints; however, it has yet to be evaluated for use in periprosthetic shoulder infection. QUESTIONS/PURPOSES: (1) Is D-dimer elevated in patients with probable or definite periprosthetic shoulder infections? (2) What is the diagnostic accuracy of D-dimer for periprosthetic shoulder infections? (3) What are the diagnostic accuracies of serum tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), singly and in combination? METHODS: Between March 2016 and March 2020, 94 patients undergoing revision total shoulder arthroplasty (anatomic or reverse) at a single institution had preoperative serum testing with CRP, ESR, and D-dimer. These 94 patients were a subset of 189 revision shoulder arthroplasties performed at this institution during the study period who met inclusion criteria and consented to participate. Included patients had a mean ± SD age of 69 ± 8 years, and 56% (53 of 94) were men. Patient records were reviewed to classify patients as definitely having infection, probably having infection, possibly having infection, or unlikely to have an infection, according to the International Consensus Meeting (ICM) definition of periprosthetic shoulder infection. Statistical analyses, including a receiver operating characteristic curve analysis, were performed to quantify the diagnostic value of D-dimer for periprosthetic shoulder infection. Based on the ICM definition, 4% (4 of 94), 15% (14 of 94), 14% (13 of 94), and 67% (63 of 94) of patients had definite, probable, possible, or unlikely periprosthetic shoulder infections. RESULTS: D-dimer was elevated in patients with definite or probable infections (median [range] 661 ng/mL [150 to 8205]) compared with those with possible infections or those who were unlikely to have an infection (263 ng/mL [150 to 3060]; median difference 143 ng/mL [95% CI 40 to 503]; p = 0.01). In the receiver operating characteristic curve analysis, D-dimer had an area under the curve of 0.71 (0.50-0.92), demonstrating weak diagnostic value. A D-dimer level of 598 ng/mL provided a sensitivity and specificity of 61% (95% CI 36% to 82%) and 74% (95% CI 62% to 83%), respectively, for diagnosing a definite or probable infection according to the ICM definitions. The specificity of detecting periprosthetic joint infection (88% [95% CI 79% to 94%]) was high when three positive serum markers (ESR, CRP, and D-dimer) were required, at the expense of sensitivity (28% [95% CI 10% to 53%]). CONCLUSION: In periprosthetic shoulder infection, D-dimer is elevated. However, similar to other serum tests, it has limited diagnostic utility in identifying patients with periprosthetic shoulder infection. Further work is needed to understand the process by which D-dimer is associated with active infection. LEVEL OF EVIDENCE: Level III, diagnostic study.

Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations.

INTRODUCTION: Proximal humeral fracture with associated glenohumeral dislocation (PHFD) is a challenging clinical problem. Outcomes of open reduction and internal fixation (ORIF) of these injuries have not been widely reported. The purpose of this analysis is to report our experience with ORIF of PHFD. METHODS: A retrospective review of our 2 institutions' shoulder surgery databases was conducted to identify all PHFDs that were treated with ORIF from 2008 through 2017. Radiographs were reviewed for fracture healing by 12 weeks postoperatively. All reoperations were recorded. Patient-reported outcomes using Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores at a minimum 2-year follow-up were recorded. RESULTS: There were 20 PHFDs identified: they were 50% male, 55.8 ± 10.3 years old (range 31.3-66.3), and had a body mass index of 29.3 ± 8.2 (15.2-47.8). Seven (35%) patients experienced varus collapse, nonunion, or avascular necrosis and 6 (30%) patients underwent reoperation. Of the 17 patients who did not go on to revision or arthroplasty, 14 (82.3%) had patient-reported outcomes at a mean follow-up of 4.9 ± 2.2 years (2.3-8.8). These patients had an average SST 8.0±4.0 yes responses (0-12) and ASES scores of 71.6 ± 20.4 (20.2-94.9). CONCLUSION: ORIF of PHFD carries a high rate of reoperation. In patients who achieve healing, functional scores are satisfactory. This information is important for proper patient counseling prior to surgery.

What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty?

BACKGROUND: Cultures taken at the time of primary shoulder arthroplasty are commonly positive for Cutibacterium acnes. Despite our limited understanding of the clinical implication of deep tissue inoculation from dermal colonization, significant efforts have been made to decolonize the shoulder prior to surgery. The purpose of this study is to determine differences in clinical outcomes based on culture positivity at the time of primary shoulder arthroplasty. METHODS: A series of 134 patients who underwent primary anatomic or reverse total shoulder arthroplasty and had intraoperative cultures obtained via a standard protocol were included. In each case, 5 tissue samples were collected and processed in a single laboratory for culture on aerobic and anaerobic media for 13 days. Minimum 2-year functional outcomes scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Single Assessment Numeric Evaluation [SANE]) and reoperation data were analyzed. RESULTS: Forty-two (31.3%) patients had positive cultures (30 C acnes and 21 with at least 2 positive cultures) at the time of surgery. There was no statistically significant difference in postoperative functional outcome scores (ASES: 82.5 vs. 81.9; P = .89, SANE: 79.5 vs. 82.1; P = .54) between culture-positive and culture-negative cohorts. There were no cases of infection. Two patients (4.8%; 2/42) with positive cultures required reoperation compared with 4 patients (5.6%; 4/71) without positive cultures. CONCLUSION: The apparent colonization by nonvirulent organisms in patients undergoing primary shoulder arthroplasty does not appear to have a clinically significant effect on functional outcomes or need for repeat surgery in the short term.

Cutibacterium acnes is Isolated from Air Swabs: Time to Doubt the Value of Traditional Cultures in Shoulder Surgery?

BACKGROUND: Given high rates of positive Cutibacterium acnes (C. acnes) cultures in cases of both primary and revision shoulder surgery, the ramifications of positive C. acnes cultures remain uncertain. Next generation sequencing (NGS) is a molecular tool that sequences the whole bacterial genome and is capable of identifying pathogens and the relative percent abundance in which they appear within a sample. The purpose of this study was to report the false positive culture rate in negative control specimens and to determine whether NGS has potential value in reducing the rate of false positive results. METHODS: Between April 2017 and May 2017 swabs were taken during primary shoulder arthroplasty. After surgical time out, using sterile gloves, a sterile swab was opened and exposed to the air for 5 seconds, returned to its contained, and sealed. One swab was sent to our institution's microbiology laboratory for aerobic and anaerobic culture and held for 13 days. The other sample was sent for NGS (MicroGen Dx, Lubbock, TX), where samples were amplified for pyrosequencing using a forward and reverse fusion primer and matched against a DNA library for species identification. RESULTS: For 40 consecutive cases, swabs were sent for culture and NGS. C. acnes was identified by culture in 6/40 (15%) swabs and coagulase negative staphylococcus (CNS) was identified in 3/40 (7.5%). Both cases with positive NGS sequencing reported polymicrobial results with one sample (2.5%), including a relative abundance of 3% C. acnes. At 90 days after surgery, there were no cases of clinical infection in any of the 40 cases. CONCLUSION: We demonstrate that the two most commonly cultured organisms (C. acnes and CNS) during revision shoulder arthroplasty are also the two most commonly cultured organisms from negative control specimens. Contamination can come from air in the operating room or laboratory contamination.

Cutibacterium acnes is less commonly identified by next-generation sequencing than culture in primary shoulder surgery.

INTRODUCTION: High rates of positive Cutibacterium acnes cultures from primary shoulder surgery make positive cultures in the revision surgery setting difficult to interpret. Our goal was to determine concordance between culture and next-generation sequencing techniques for identification of C. acnes from primary shoulder surgery. METHODS: Patients undergoing shoulder arthroscopy for rotator cuff tear or primary anatomic shoulder arthroplasty for osteoarthritis were prospectively enrolled. Specimens were sent for culture (aerobic and anaerobic) and next-generation sequencing. For next-generation sequencing, the entire microbial DNA was sequenced in order to identify pathogens within the sample. RESULTS: Our cohort consisted of 90 patients (45 patients in the osteoarthritis group and 45 patients in the rotator cuff tear group). At least one sample was positive for C. acnes in 18 (20%) cases by culture and in 14 (15.6%) cases by next-generation sequencing (p = 0.559). Four (22.2%) of the 18 cases with positive C. acnes cultures also had C. acnes identified by next-generation sequencing (kappa = 0.238). There was no difference in C. acnes identification rates between osteoarthritis and rotator cuff tear groups. CONCLUSIONS: There was limited concordance between culture and next-generation sequencing for C. acnes identification. Further studies are needed to determine the potential for next-generation sequencing as a diagnostic tool.

Clinically significant subscapularis failure after anatomic shoulder arthroplasty: is it worth repairing?

BACKGROUND: Symptomatic subscapularis (SC) failure after anatomic total shoulder arthroplasty (TSA) is difficult to treat. The purpose of this study was to determine the outcomes of reoperation for SC failure. METHODS: All patients undergoing reoperation for SC failure after TSA were identified from a single-institution database. Patients underwent either revision SC repair or revision to reverse shoulder arthroplasty. At a minimum of 1 year after reoperation, complications, reoperations, and functional outcomes were collected. RESULTS: Patients who initially underwent SC repair were significantly younger than patients who underwent revision to reverse shoulder arthroplasty (mean age, 59.3 years vs. 70.3 years; P = .004), had a better comorbidity profile (mean Charlson Comorbidity Index, 2.2 vs. 3.6; P = .04), and had a more acute presentation (mean time between injury and surgery, 9.1 weeks vs. 28.5 weeks; P = .03). Patients who underwent SC repair also had a significantly higher reoperation rate (52.9% vs. 0.0%, P = .01). At final follow-up, functional outcomes scores and patient satisfaction rates were not significantly different between treatment groups. DISCUSSION: Decision making on how to treat patients with SC failure following TSA remains challenging and should be individualized to the patient's age, level of activity, comorbidities, timing and mechanism of SC failure, and functional expectations.

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial.

BACKGROUND: Hydrogen peroxide is an inexpensive and effective antimicrobial agent that can be implemented in surgical skin preparations. The purpose of this study was to evaluate the decolonization effect of Cutibacterium acnes when adding hydrogen peroxide to a standard sterile preparation for shoulder surgery. METHODS: This was a single-institution, prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy (April 2018 and May 2019). Patients were randomized to a standard skin preparation vs. an additional sterile preparation with 3% hydrogen peroxide. After draping, a 3-mm punch biopsy was obtained from the posterior arthroscopic portal site of all patients. Anaerobic and aerobic culture substrates were used and held for 13 days. RESULTS: Seventy male patients were randomized into the hydrogen peroxide group and 70 male patients were in the traditional group. Twelve (17.1%) patients in the hydrogen peroxide group and 24 (34.2%) patients in the traditional group had positive cultures for C acnes (P = .033). Cultures were positive at a mean of 4.5 days (range 3-7) in the hydrogen peroxide group and 4.1 days (range 3-8) in the traditional group (P = .48). There were no cases of skin reaction to the surgical preparation in either group. DISCUSSION: The results of this study suggest that the addition of hydrogen peroxide to preoperative surgical site preparation can reduce the C acnes culture rate. Hydrogen peroxide is inexpensive and can be added to the typical skin preparation used prior to shoulder surgery without substantial risk of skin reactions.

Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss.

INTRODUCTION: Structural glenoid bone grafting in reverse total shoulder arthroplasty (RSA) has previously been reported to have good functional outcomes and low complication rates. We have observed different complication rates and hypothesized that baseplate fixation and severity of deformity may be predictors of early failure. METHODS: We retrospectively identified 44 patients who underwent RSA with structural bone grafting for glenoid bone defects. All patients had preoperative and postoperative (Grashey and axillary) radiographs at a minimum of 1 year after surgery and within 3 months of surgery for evaluation of implant and graft positioning. Clinical data and outcome scores were collected at the same intervals. RESULTS: There were 61% females and 39% males, with an average age of 74 ± 8 years at the time of surgery. The median final radiographic follow-up was 20 months, with 37 primary RSA and 7 revision RSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Forward elevation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores all significantly improved postoperatively (P < .0001). Radiographic baseplate failure was associated with graft resorption (P = .002), more retroversion correction (P = .02), and worse SANE scores at final follow-up (P = .01). DISCUSSION/CONCLUSION: RSA with structural bone graft improved range of motion and function, but there was a larger than previously reported baseplate loosening rate. This early radiographic loosening appeared to be associated with graft resorption, retroversion correction, and worse outcome scores.

Outcomes of shoulder arthroplasty following axillary lymph node dissection.

INTRODUCTION: Shoulder arthroplasty with previous axillary lymph node dissection historically has unsatisfactory outcomes. We analyzed outcomes of primary shoulder arthroplasty in patients with previous axillary lymph node dissection. METHODS: Thirty-two primary shoulder arthroplasties after prior axillary lymph node dissection were performed. These patients were analyzed for patient-reported outcomes, range of motion, complications, and reoperations. RESULTS: Average age was 70.8 ± 7.5 years old. There were 19 anatomic total shoulder arthroplasties, four hemiarthroplasties, and nine reverse total shoulder arthroplasties. Eight were performed by a superior approach while 24 were performed by a deltopectoral approach with cephalic vein preservation. There were three complications (one deltoid dehiscence, one axillary nerve palsy, and one postoperative pneumonia). There was one revision (hemiarthroplasty to reverse total shoulder arthroplasty for cuff failure at 91 weeks), two reoperations, and no infections. Patient-reported outcomes were available for 21/26 (80.1%) of the surviving shoulders at 4.8 ± 2.0 years. Average visual analog scale pain score was 7.1 ± 14.5, Simple Shoulder Test score 8.3 ± 2.6 "yes" responses, Single Assessment Numeric Evaluation score 80.2 ± 17.4, and American Shoulder and Elbow Surgeons score 83.6 ± 14.1. CONCLUSION: Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. A deltopectoral exposure can be utilized without substantial risk of worsening lymphedema or wound complications. While a superior approach avoids cephalic vein injury, important approach-related complications (deltoid dehiscence and axillary nerve palsy) were observed.Level of evidence: Level IV-case series.

Rotational Osteotomy of the Humeral Shaft for Malunion in Osteogenesis Imperfecta: A Case Report.

CASE: We report a case of an adult with osteogenesis imperfecta, who underwent humeral shaft osteotomy to correct an internal rotation deformity results from a humeral shaft malunion. The patient incurred a temporary radial nerve palsy. CONCLUSIONS: Humeral shaft malunion can be successfully treated with rotational osteotomy of the humerus through an anterior approach; however, the risk of radial nerve palsy exists and may be minimized by a posterior approach.

Failure of Anatomic Total Shoulder Arthroplasty with Revision to another Anatomic Total Shoulder Arthroplasty.

BACKGROUND: While outcomes of primary anatomic total shoulder arthroplasty (aTSA) are generally favorable, results after revision procedures are less reliable. This study examines the functional outcomes, complications, and implant survival in patients who underwent revision of aTSA to aTSA. METHODS: Patients who underwent revision aTSA were identified from 2008-2015. Demographic, clinical, surgical, and outcomes data were analyzed. Patient-reported outcomes including the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numerical Evaluation (SANE), Visual Analog Scale for pain (VAS), the Short Form-12 Health Survey (SF-12), and patient satisfaction were recorded. RESULTS: Twenty patients underwent revision from a primary aTSA to aTSA (55% male, 62.0±6.8 years-old). Revision aTSA occurred at 2.5±3.4 years after index surgery. Seven (35%) required future revision at 1.8±1.9 years after revision aTSA. Among the 13 patients who did not undergo revision, twelve (92.3%) had over two-year follow-up (4.0±2.4 years). Average ASES score was 70.1±23.5, SANE 66.0±29.4, VAS 2.7±3.0, SF-12 Mental 52.4±10.5, SF-12 Physical 36.8±8.9, and satisfaction of 3.6±1.2. CONCLUSION: Results of revision aTSA to aTSA were unpredictable and the revision rate was high. The cases that do not undergo revision had satisfactory, but inconsistent functional results. Reverse arthroplasty may be more reliable in this patient population.