Cementless reverse total shoulder arthroplasty implantation with humeral matchstick autograft augmentation: early radiographic outcomes.

BACKGROUND: Humeral-sided complications account for up to 21% of all revision reverse total shoulder arthroplasty (RTSA) surgeries. Stress shielding with large bulky stems can lead to proximal bone resorption per Wolff law, complicating further surgeries. Previously published studies suggest that lowering the metaphyseal implant fill ratio can lead to fewer adaptive radiographic changes and decreased bone resorption. Inspired by these studies, cementless primary RTSA implantation technique with humeral matchstick autografts was proposed to augment cementless humeral constructs, foster the use of a smaller size stem, and create primary stability of the humeral implant even in osteoporotic or in-between size medullary canals. In this study, retrospective review of this cementless RTSA technique with short-term radiographic evaluation was performed. METHODS: Forty-six nonconsecutive patients underwent primary RTSA with a short-stem cementless prosthesis (Stryker Ascend Flex) augmented by matchstick bone grafting from January to July 2020. Patient demographics were recorded, and follow-up radiographs were retrospectively reviewed to assess metaphyseal fill ratios and incidence of stress shielding at minimum 1-year follow-up. Discrepancies between templated and final stem sizes were recorded, along with all intraoperative and postoperative complications. RESULTS: Of the 46 patients originally identified, there were 5 men and 41 women with a mean age of 71 years (standard deviation [SD] 7, range 53-88). Mean templated stem size was 4 (SD 2, range 1-8), whereas the mean final implant size was 2 (SD 1, range 1-3). Mean fill ratios were 0.76 (SD 0.06, range 0.54-0.89) along the metaphysis and 0.67 (SD 0.09, range 0.49-0.83) along the diaphysis. There were no intraoperative humeral fractures from implantation. All patients were available for radiographic follow-up with a mean of 19 months (SD 8, range 12-40). There were 3 cases (7%) of proximal humeral stress shielding, with average fill ratios of 0.857 and 0.807 in the metaphysis and diaphysis, respectively. There were 3 patients (7%) who underwent revision surgeries for baseplate failure and periprosthetic humeral fracture. There were no cases of early humeral loosening. DISCUSSION: Matchstick autograft humeral augmentation is a simple, promising surgical technique with low intraoperative complication rates and good short-term radiographic outcomes. When the implant fill ratio is successfully reduced, there is a possible lower risk of humeral stress shielding. The authors believe this technique can help maximize implant stability in cementless shoulder arthroplasty and preserve humeral bone stock for future revision surgeries.

Yoke procedure as a salvage treatment option for failed reverse total shoulder arthroplasty with irreconstructible glenoid.

BACKGROUND: Glenoid bone loss is a known challenge in primary and revision reverse total shoulder arthroplasty. In severe deficiency, even placing the baseplate in alternative centerline or using an augmented baseplate may be insufficient. This study reports on the use of a soft tissue resurfacing technique using Achilles tendon allograft, coined Yoke procedure, for salvage treatment of glenoid deficient shoulder requiring reconstruction. MATERIALS AND METHODS: All patients who underwent the Yoke procedure between 2014 and 2020 by a single surgeon at a single academic center were identified and had their charts retrospectively reviewed. Demographics and surgical information were recorded. Preoperative X-rays and 3D-computed tomography scans were reviewed to classify patient glenoid types, evaluate glenoid medialization, and measure shoulder angles. Preoperative and postoperative range of motions and patient-reported outcome scores were evaluated, including anterior elevation, external rotation, internal rotation, visual analog scale, subjective shoulder value score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons (ASES) scores. Postoperative radiographs and follow-up notes were reviewed to evaluate postoperative complication profiles at 1 year. RESULTS: Seven patients with a median age of 69 years (range, 54-77 years) underwent Yoke procedure and had a median 12-month follow-up (range, 9-56 months). All patients were female and had a median of 2 prior shoulder surgeries (range, 0-13). Of all the patients, the most common comorbidity was osteoporosis (6) followed by rheumatoid arthritis (3). Of the 5 patients who had previous arthroplasty, the most common indications were baseplate failure (4), followed by instability (3) and infection (3). The median visual analog scale score improved from 8 (range, 3-9) to 2 (range, 1-4). The median Simple Shoulder Test improved from 8% (range, 0%-42%) to 33% (range, 17%-83%). The median ASES score improved from 15 (range, 5-38) to 52 (range, 40-78). The median anterior elevation and external rotation improved from 20° (range, 0°-75°) to 100° (range, 40°-145°) and 10° (range, 0°-20°) to 20° (range, 0°-55°), respectively. There was no change in median internal rotation. As of the last follow-up, one patient reported postoperative complications of anterior-superior implant escape, heterotopic ossification, and scapular notching. CONCLUSION: The Yoke procedure is a promising salvage treatment that can offer patients consistent pain reduction and moderate functional improvements at short-term follow-up. In the setting of poor bone quality and severe glenoid deficiency, glenoid baseplate implantation may not be absolutely necessary for a pain-relieving, functionally acceptable outcome.

Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly.

Introduction: in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients. Materials & Methods: Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union. Results: There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding. Conclusion: Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

Voicing narratives of structural violence in interpersonal firearm violence research and prevention in the United States.

Violence is defined as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation." Encompassed in this definition are multiple, interrelated forms of violence, including interpersonal firearm death and injury, but also the systems, policies, and practices enacted by those with power to advantage some groups while depriving others of meaningful opportunities for meeting their basic needs-known as "structural violence". Yet dominant violence prevention narratives too often ignore or deemphasize the deeply intertwined threads of structural violence with other forms of violence, leading to policies and practices that are frequently insufficient, and often harmful, for reducing interpersonal firearm violence and building community safety, particularly in minoritized and structurally marginalized communities. We highlight ways in which limited scrutiny of structural violence, the omission of its defining characteristics-power and deprivation-from functional characterizations and frameworks of interpersonal firearm violence, and the inadequate distribution of power and resources to those most impacted by violence to self-determine narratives of and solutions to interpersonal firearm violence grossly impacts how interpersonal firearm violence is collectively conceived, discussed, and addressed. Expanding dominant narratives of interpersonal firearm violence, guided by the wisdom and determination of those most impacted, such that the goal of prevention and intervention efforts is not merely the absence of violence but rather the creation of a community safety and health ecosystem is essential to meet this critical moment in firearm violence research and prevention.

Changes in suicide in California from 2017 to 2021: a population-based study.

BACKGROUND: Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. METHODS: We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. RESULTS: Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas. CONCLUSIONS: The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.

Changes in self-harm and suicide in California from 2017-2021: a population-based study.

Background : Self-harm and suicide are major public health problems with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of fatal and nonfatal intentional self-harm in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. Methods: We used California-wide death data and University of California (UC)-wide hospital data to summarize fatal and nonfatal instances of intentional self-harm across race/ethnicity, age, education, gender, region, and method of harm. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. Results : Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10-19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20-29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. Counts and rates of nonfatal, intentional self-harm in UC hospitals increased in 2020 (2160; 30.7 per 100,000) and 2021 (2175; 30.9 per 100,000) compared to pre-pandemic (2083; 29.6 per 100,000), especially among young people (age 10-19), females, and Hispanic Californians. Conclusions : The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of self-harm and suicide across the California population. Marginalized racial groups, females, and younger people experienced increased risk for self-harm, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal and nonfatal self-harm injuries and reduce related inequities.

Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection.

INTRODUCTION: Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. MATERIALS AND METHODS: Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. RESULTS: Mean age of the cohort was 68 (standard deviation [SD] 8.9) years and mean follow-up was 33 (SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2 (SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. DISCUSSION: Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution. METHODS: From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection. RESULTS: Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection. CONCLUSION: Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Comprehensive Modified Latarjet Technique: What the Masters Taught Us.

The Latarjet surgical technique is one of the most effective and well-known techniques in the treatment of anterior shoulder instability1. The modified Latarjet technique is a history book of surgical details demonstrated by renowned masters of shoulder surgery. The procedure includes soft-tissue repair and osseous reconstruction to stabilize the glenohumeral joint in recurrent anterior instability. The procedure has been shown to have reliable success in reducing recurrent instability and minimizing risk of dislocation arthropathy2-4. DESCRIPTION: The Latarjet technique can be performed via a cosmetic axillary-based approach. The subscapularis is split horizontally without detachment as described by Neer5. The capsule is released like in a medially based T-plasty as described by Altchek et al.6. The coracoid osteotomy is performed with a 90° oscillating saw and prepared for en-face implantation as described by Edwards and Walch7. The inferior surface of the coracoid is decorticated and prepared per Molé8. Coracoid fixation is performed with two 3.5-mm cortical screws. The soft-tissue reconstruction is selectively tensioned per Warner et al.9. The capsular shift is augmented with a pants-over-vest repair per Kim et al.10. ALTERNATIVES: Nonoperative treatment in young patients with glenohumeral instability and bone loss can lead to recurrence rates as high as 87%11. Arthroscopic management with anterior capsulolabral repair and a remplissage procedure can be beneficial for patients with instability. In the setting of bone loss, arthroscopic repair is associated with failure rates as high as 75%12. RATIONALE: In the setting of glenoid and/or humeral bone loss, there is a loss of native osseous anatomy, leading to a higher risk of instability. Gerber and Nyffeler reported a >30% loss of compressive force when the vertical edge of the glenoid defect is greater than one-half of the glenoid diameter13. The Latarjet procedure is a reliable procedure that reconstructs the anterior osseous anatomy as well as the capsular laxity, restoring glenohumeral stability. When compared with arthroscopic labral repair, the Latarjet procedure is superior with more consistent improvements in functional outcomes with low risk of recurrence, even in high-risk populations of young, active athletes in contact sports2,3. EXPECTED OUTCOMES: At our institution, a total of 34 patients underwent Latarjet reconstruction as described in the present article and videos from 2013 to 2018, with a minimum follow-up of 1 year. Among these patients, the mean Single Assessment Numeric Evaluation score was 90.7 (range, 70 to 100). There were 4 cases of recurrent instability with graft fracture or resorption (11.8%). Zimmermann et al. presented a series of Latarjet reconstructions with similar functional outcomes and a recurrence rate of 11%4. Meta-analysis of long-term Latarjet studies show high rates of return to sports and successful outcomes in 86% of cases, with an 8.5% recurrence rate2. IMPORTANT TIPS: The Latarjet procedure can be consistently performed with a subscapularis-sparing approach, which minimizes adverse comorbidities.Splitting the subscapularis at the inferior one-third junction will position the surgical window directly over the bottom half of the glenoid, which optimizes coracoid implantation.A medially based T-plasty will maximize the glenoid exposure for direct coracoid implantation. Subsequently, the capsule may be shifted for capsular imbrication.Low-profile, non-bulky retractors will help to improve visualization.Adjusting the arm is a key technique in performing this surgical procedure. This adjustment will help to shift the surgical window, expose key anatomic structures, and allow a capsular shift without overtensioning. This cannot be overstated.

The association between three key social determinants of health and life dissatisfaction: A 2017 behavioral risk factor surveillance system analysis.

Poor health outcomes disproportionately impact certain populations in the United States owing to the inequitable distribution of social determinants of health (SDOH). Using the 2017 Behavioral Risk Factor Surveillance System (BRFSS), we estimated the association of three adverse SDOH (housing insecurity, food insecurity, and financial instability) with life dissatisfaction. Participants were from Wisconsin, Minnesota, and Ohio, the only states that included the SDOH and Emotional Support and Life Satisfaction modules (n = 25,850). Six percent of respondents reported life dissatisfaction. Those who reported housing insecurity (Prevalence difference (PD) = 14.2 per 100, 95% CI [7.6, 20.7]), food insecurity (PD = 10.9 [7.1, 14.7]), and financial instability (PD = 5.6 [4.9, 6.3]) had higher prevalence of life dissatisfaction. The differences in prevalence of life dissatisfaction, comparing those with and without an adverse SDOH, decreased with increased emotional support (for housing insecurity, food insecurity, and financial instability, respectively: low support, PD = 30.2 [11.6, 48.8], 22.1 [11.6, 32.6], 16.4 [12.0, 20.8]; high support, PD = 4.8 [-2.9, 12.6], 4.8 [0.0, 9.7], 1.7 [1.1, 2.3]). Participants with frequent mental distress (FMD) had greater prevalence differences than those without FMD (for housing insecurity, food insecurity, and financial instability, respectively: with FMD, PD = 15.4 [7.5, 23.3], 10.7 [4.7, 16.7], 14.4 [9.6, 19.3]; without FMD, PD = 6.1 [-0.5, 12.5], 5.3 [1.6, 9.0], 2.5 [2.0, 3.0]). Social determinants may not only influence physical health but also have an impact on psychological well-being. This impact may be altered by levels of emotional support and FMD.