Staged Repair of Bilateral Isolated Teres Major Tears: A Case Report.

CASE: A 58-year-old, very active man sustained bilateral isolated teres major (TM) tendon tears when his arms were forcefully elevated overhead while wakeboarding. Staged surgical repair was performed. A progressive rehabilitation protocol was followed, and he returned to high-level activities 7 months postoperatively. At 1-year follow-up, outcome measures for bilateral shoulders were DASH 0, SST 12, ASES 100, and EQ-5D 1.0. CONCLUSION: Despite literature supporting conservative treatment, this case demonstrates that operative treatment of acute, isolated TM tears can result in highly successful outcomes for motivated active patients.

Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review.

PURPOSE: With a lack of standardization among outcome measures in fracture literature, cross-study comparisons remain limited. This systematic review aimed to identify trends in outcome measures reported by studies of the treatment of humeral shaft fractures. METHODS: A systematic review was performed of studies reporting clinical outcomes of humeral shaft fractures indexed in PubMed. Extracted data included demographics, fracture characteristics, treatment modalities, outcomes, patient reported outcome measures (PROMs), and journal characteristics. Cochran-Armitage tests and linear regressions were used to identify data trends. Pearson chi-square and Kruskal-Wallis tests were used for comparisons between studies. RESULTS: This review included 197 studies with outcomes of 15,445 humeral shaft fractures. 126 studies reported PROMs and 37 different PROMs were used. The Constant Score was most commonly reported (34% of studies), followed by ASES Score (21%), MEPS (21%), and DASH Score (20%). There was a significant increase in PROM usage over time (p = 0.016) and in articles using three or more PROMs (p = 0.005). The number of PROMs were significantly greater in prospective cohort studies and RCTs (p = 0.012) compared to retrospective cohort studies and case series (p = 0.044 for both). Post-treatment shoulder motion was reported in 43% of studies and 34% reported elbow motion. 86% of studies reported complications as an outcome parameter. Time to union and nonunion rate were published in 69% and 88% of studies, respectively. CONCLUSION: This study identified increasing PROM usage over time and disparities in the reporting of outcomes in humeral shaft fracture literature requiring further validation and standardization of available outcome measures.

Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide.

Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.

Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report.

CASE: A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus. CONCLUSION: Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.

The effect of concurrent cervical spine degenerative disease on the outcome of rotator cuff repair: a national database study.

BACKGROUND: Cervical spine degenerative disease (CSD) can cause shoulder pain, potentially confounding the management of patients with rotator cuff tears. This study aimed to investigate the relationships between CSD and rotator cuff repair (RCR). METHODS: A national administrative database (PearlDiver) was used to study 4 patient cohorts: (1) RCR only (RCRo), (2) RCR with concurrent CSD (RCRC), (3) RCR after a cervical spine procedure (RCRA), and (4) RCR before a cervical spine procedure (RCRB). The outcomes of RCR were compared using multivariable logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index, as well as preoperative opioid utilization in the analysis of opioid use. RESULTS: Between 2010 and 2021, a total of 889,977 patients underwent RCR. Of these patients, 784,230 (88%) underwent RCRo whereas 105,747 (12%) underwent RCRC, of whom 21,585 (2.4%) underwent cervical spine procedures (RCRA in 9670 [1.1%] and RCRB in 11,915 [1.3%]). At 2 years after RCR, compared with RCRo patients, RCRC patients had an increased risk of surgical-site infection (adjusted odds ratio [aOR] = 1.25, P = .0004), deep vein thrombosis (aOR = 1.17, P = .0002), respiratory complications (aOR = 1.19, P = .0164), and ipsilateral shoulder reoperations (débridement [aOR = 1.66, P < .0001], manipulation under anesthesia or arthroscopic lysis of adhesions [aOR = 1.23, P < .0001], distal clavicle excision [aOR = 1.78, P < .0001], subacromial decompression [aOR = 1.72, P < .0001], biceps tenodesis [aOR = 1.76, P < .0001], incision and drainage [aOR = 1.34, P = .0020], synovectomy [aOR = 1.48, P = .0136], conversion to shoulder arthroplasty [aOR = 1.62, P < .0001], revision RCR [aOR = 1.77, P < .0001], and subsequent contralateral RCR [aOR = 1.71, P < .0001]). At 2 years, compared with RCRC patients who did not undergo cervical spine procedures, RCRC patients who underwent cervical spine procedures had an increased risk of incision and drainage (aOR = 1.50, P = .0255), conversion to arthroplasty (aOR = 1.40, P < .0001), and revision RCR (aOR = 1.11, P = .0374), as well as a lower risk of contralateral RCR (aOR = 0.89, P = .0469). The sequence of cervical spine procedures did not affect the risk of shoulder reoperations. At 1 year, the risk of opioid use after RCR was less for RCRA patients compared with RCRB patients (aOR = 1.71 [95% confidence interval, 1.61-1.80; P < .0001] vs. aOR = 2.01 [95% confidence interval, 1.92-2.12; P < .0001]). CONCLUSION: Concurrent CSD has significant detrimental effects on RCR outcomes. Patients with concurrent CSD undergoing cervical spine procedures have a greater risk of ipsilateral shoulder reoperations but a decreased risk of contralateral RCR. The risk of prolonged opioid use was lower if RCR followed a cervical spine procedure. Concurrent CSD must be considered and possibly treated to optimize the outcomes of RCR.

Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty: A Matched-Cohort Study.

BACKGROUND: Glenoid component failure is a major concern after anatomic total shoulder arthroplasty (aTSA). Ream and run (RnR) is an alternative procedure that may avoid glenoid-related complications. The purpose of this study was to compare outcomes of RnR versus aTSA in younger patients with advanced glenohumeral osteoarthritis. METHODS: This was a retrospective matched-cohort study of 110 patients who underwent aTSA and 57 patients who underwent RnR; patients were <66 years of age and had a minimum of 2 years of follow-up. Propensity matching was performed using 21 preoperative variables. Pre- and postoperative patient-reported outcome measures (PROMs) and health-related quality-of-life (HRQoL) scores, satisfaction with outcome, and revision data were analyzed. Mixed-effects models examined the association of preoperative variables with outcomes. RESULTS: Thirty-nine patient pairs were matched. All patients were male, with a mean age of 58.6 ± 7.3 years and a mean follow-up 4.4 ± 2.3 years. The aTSA cohort had better final Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) scores. However, in the mixed-effects model analysis, arthroplasty type was not associated with outcome. At 2 years postoperatively, a significantly greater percentage of aTSA patients achieved the substantial clinical benefit (SCB) for the ASES (100% versus 79.2%; p = 0.01) and the minimal clinically important difference (MCID) (89.7% versus 75%; p = 0.02) for the visual analog scale (VAS) for pain. At >5-year follow-up, there were no significant differences between the cohorts in the percentage who achieved the MCID, SCB, or patient acceptable symptom state (PASS) for the ASES, SST, and VAS for pain. Three patients underwent revision arthroplasty for pain after RnR, at a mean of 1.9 ± 1.7 years. Two patients underwent revision arthroplasty for glenoid loosening at 9.2 and 14 years after aTSA. CONCLUSIONS: RnR and aTSA had comparable outcomes in most analyses. The greater early revision rate after RnR should focus attention on optimizing patient selection and postoperative management. Revision for glenoid loosening is a concern among younger and active patients. Longer-term study is needed to better understand the relative benefits and disadvantages of these procedures. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Increased Risk of Periprosthetic Fractures and Revision Arthroplasty in Patients Undergoing Shoulder Arthroplasty With a History of Prior Fragility Fractures: A Matched Cohort Analysis.

INTRODUCTION: As rates of anatomic and reverse total shoulder arthroplasty (SA) continue to grow, an increase in the number of osteoporotic patients undergoing SA, including those who have sustained prior fragility fractures, is expected. The purpose of this study was to examine short-term, implant-related complication rates and secondary fragility fractures after SA in patients with and without a history of fragility fractures. METHODS: A propensity score-matched retrospective cohort study was done using the PearlDiver database to characterize the effect of antecedent fragility fractures in short-term complications after SA. Rates of revision SA, periprosthetic fractures, infection, and postoperative fragility fractures were evaluated using multivariate logistic regression analysis. Risks of these complications were also studied in patients with and without preoperative osteoporosis treatment. Statistical significance was set at P < 0.05. RESULTS: A total of 91,212 SA patients were identified, with 13,050 (14.3%) experiencing a fragility fracture within the 3 years before SA. Two years after SA, there were increased odds of periprosthetic fracture (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.68 to 2.99), fragility fracture (OR 9.11, 95% CI 8.43 to 9.85), deep infection (OR 1.68, 95% CI 1.34 to 2.12), and all-cause revision SA (OR 1.68, 95% CI 1.44 to 1.96) within those patients who had experienced a fragility fracture within 3 years before their SA. Patients who were treated for osteoporosis with bisphosphonates and/or vitamin D supplementation before their SA had similar rates of postoperative periprosthetic fractures, fragility fractures, and all-cause revision SA to those who did not receive pharmacologic treatment. CONCLUSION: Sustaining a fragility fracture before SA portends substantial postoperative risk of periprosthetic fractures, infection, subsequent fragility fractures, and all-cause revision SA at the 2-year postoperative period. Pharmacotherapy did not markedly decrease the rate of these complications. These results are important for surgeons counseling patients who have experienced prior fragility fractures on the risks of SA.

Early outcome of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for treatment of advanced glenohumeral osteoarthritis.

INTRODUCTION: Long-term outcomes of anatomic total shoulder arthroplasty (aTSA) can be compromised by glenoid loosening and failure. The purpose of this study was to evaluate the short- and midterm outcomes of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for the treatment of advanced glenohumeral osteoarthritis, and to identify associations between preoperative factors and outcomes. METHODS: Forty-nine shoulders (mean age 60 ± 7 years) with minimum 2-year follow-up (mean 4.6 ± 1.7) were evaluated. Forty-three (87.8%) were male. Thirteen (26.5%) had previous nonarthroplasty shoulder surgery. There were 19 (38.8%) Walch type A and 30 (61.2%) type B glenoids. Pre- and postoperative shoulder motion, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) were assessed. Pre- and postoperative plain radiographs were evaluated. Mixed effects models were used to investigate factors associated with outcomes. RESULTS: Active forward elevation and active external rotation improved from 111.7° ± 23.8° to 139.2° ± 21.1° and 13.3° ± 20.7° to 38.7° ± 14.7°, respectively (P < .001). The mean American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) shoulder pain scores at the most recent follow-up were 86.6 ± 19.9, 10.1 ± 14.1, 10.5 ± 2.2, and 1.5 ± 2.3, respectively. The mean changes of PROMs were significant and exceeded the minimal clinically important difference for aTSA. The percentage maximal possible improvement for ASES, DASH, and SST were greater than 75%. Male sex (P < .008) and not having prior shoulder surgery (P < .04) were significantly associated with better absolute and greater change in PROMs. Age, preoperative shoulder motion, and Walch glenoid classification were not associated with PROMs. Five (10.2%, 95% confidence interval [CI] 1.8%-18.6%) patients underwent revision for pain. Three additional patients were dissatisfied at final follow-up without undergoing revision, resulting in 16.7% (95% CI 6.1%-27.2%) of patients being dissatisfied with their outcome after their initial RnR. Mean Short Form-6 Dimensions scores improved from 0.66 ± 0.12 to 0.77 ± 0.13 and mean EuroQol-5 Dimensions scores improved from 0.68 ± 0.20 to 0.85 ± 0.17 (P < .001). Improvement in HRQoL was significantly associated with nondominant arm treatment, increased age, and greater preoperative SST score. Annual medialization of the humeral head center of rotation was 0.56 ± 1.6 mm/yr. No radiographic measure was associated with long-term PROMs. CONCLUSION: Ream and Run can provide significant and clinically important improvement in PROMs and HRQoL for a high percentage of patients at short- and midterm follow-up. This procedure is an appropriate alternative to aTSA in select patients.

Biomechanical Comparison of Dual and Posterior Locking Plates in an Ex Vivo Comminuted Olecranon Fracture Model.

PURPOSE: Comminuted olecranon fractures are commonly fixed with posterior locking plates (PLPs). Though biomechanically validated, this method comes with risks of symptomatic implant prominence and wound breakdown. Dual locking plates (DLPs) placed on the medial and lateral surfaces of the olecranon theoretically avoid these risks and allow for fixation of proximal fracture fragments in multiple planes. A biomechanical comparison of DLP and PLP fixation would help to validate the use of DLPs in comminuted olecranon fractures. METHODS: Seven matched pairs of cadaveric upper extremities were evaluated with quantitative computed tomography scans to evaluate bone mineral density (BMD). Osteotomies simulating comminuted olecranon fractures (Mayo Type IIB) were created and the specimens were fixed either with variable angle PLPs or variable angle DLPs. The specimens were then cyclically loaded and loaded to failure. The ultimate strength, fracture displacement, and mechanism of failure were recorded and compared across groups. The correlation between BMD and ultimate strength was analyzed. RESULTS: The mean total BMD was 0.79 g/cm2 (SD, 0.14 g/cm2). No specimen failed during cyclic testing. Five of 7 PLP specimens and 5 of 7 DLP specimens failed by fracture through the proximal screws though in different planes (sagittal vs axial splits, respectively). The mean ultimate strengths of the PLP (1077 N [SD, 462 N]) and DLP (1241 N [SD, 506 N]) groups were similar. There was a linear relationship between ultimate strength and BMD (R2 = 0.33). CONCLUSION: Dual locking plates display biomechanical properties that suggest that they can be used in the fixation of comminuted olecranon fractures. Catastrophic failure of the fixation constructs occurs around stress risers at the proximal screws rather than due to displacement at the fracture itself. CLINICAL RELEVANCE: Dual locking plate constructs can be considered for use in the fixation of comminuted olecranon fractures.

Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020.

INTRODUCTION: A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement. METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state. RESULTS: The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state. DISCUSSION: Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.

Computer-Assisted Preoperative Planning and Patient-Specific Instrumentation for Glenoid Implants in Shoulder Arthroplasty.

¼: Glenoid component positioning affects implant survival after total shoulder arthroplasty, and accurate glenoid-component positioning is an important technical aspect. ¼: The use of virtual planning and patient-specific instrumentation has been shown to produce reliable implant placement in the laboratory and in some clinical studies. ¼: Currently available preoperative planning software programs employ different techniques to generate 3-dimensional models and produce anatomic measurements potentially affecting clinical decisions. ¼: There are no published data, to our knowledge, on the effect of preoperative computer planning and patient-specific instrumentation on long-term clinical outcomes.

Outcome measures reported for the management of proximal humeral fractures: a systematic review.

BACKGROUND: The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature. METHODS: A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength. RESULTS: Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported. CONCLUSION: Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty.

BACKGROUND: Health-related quality-of-life (HRQoL) scores are required for cost-effectiveness and health-care value analysis. We evaluated HRQoL scores and patient-reported outcome measures (PROMs) in patients with advanced glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty to establish values of HRQoL scores that can be used for cost-effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs. METHODS: We analyzed 143 patients (143 shoulders) with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty; 92 patients had 1-year follow-up. Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). HRQoL score validity was determined through correlations between the PROMs and HRQoL scores. The responsiveness of HRQoL scores was measured through the effect size and the standardized response mean. RESULTS: There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. The changes in VAS QoL (very weak to moderate), EQ-5D (weak), and SF-6D (weak) were significantly correlated (p < 0.05) with the changes in PROMs, demonstrating comparably acceptable validity. There were large effect sizes in the VAS QoL (1.843), EQ-5D (1.186), and SF-6D (1.084) and large standardized response mean values in the VAS QoL (1.622), EQ-5D (1.230), and SF-6D (1.083), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores. CONCLUSIONS: PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. The findings of this study provide data on HRQoL scores that are specific to the treatment of advanced glenohumeral osteoarthritis with anatomic total shoulder arthroplasty and can be used for future cost-effectiveness and value analysis studies. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty.

BACKGROUND: Health-related quality-of-life (HRQoL) scores are required for cost-effectiveness and health-care value analysis. We evaluated HRQoL scores and patient-reported outcome measures (PROMs) in patients with advanced glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty to establish values of HRQoL scores that can be used for cost-effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs. METHODS: We analyzed 145 patients (145 shoulders) with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty; 93 patients had 1-year follow-up. Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). HRQoL score validity was determined through correlations between the PROMs and HRQoL scores. The responsiveness of HRQoL scores was measured through the effect size and the standardized response mean. RESULTS: There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. The changes in VAS QoL and EQ-5D were significantly correlated (weak to moderate) with the changes in all PROMs except the SST, demonstrating comparably acceptable validity. The VAS QoL had a large effect size (1.833) and standardized response mean (1.603), and the EQ-5D also had a large effect size (1.163) and standardized response mean (1.228), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores. The change in SF-6D had only a moderate effect size and standardized response mean and was not significantly correlated with the change in any of the PROMs. CONCLUSIONS: PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. The findings of this study provide data on HRQoL scores that are specific to the treatment of advanced glenohumeral osteoarthritis with anatomic total shoulder replacement and can be used for future cost-effectiveness and value analysis studies. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Infected Hematoma in the Setting of Nonoperatively Treated Proximal Humerus Fracture: A Report of Two Cases.

CASE: Two patients presented with infections of their recent proximal humerus fracture sites. These immunocompromised patients were being treated nonoperatively for their proximal humerus fractures; however, both were taken to the operating room for surgical debridement. CONCLUSIONS: These 2 cases demonstrate the need for further investigation into infection of closed fracture sites. Attention should be paid to immunocompromised patients who present with proximal humerus fractures, especially displaced 2-part surgical neck fractures with anterior deltoid injury and subsequent hematoma formation. These patients may develop an infection with potential rapid progression to life-threatening septic shock.

Treatment of a Complex Interprosthetic Humerus Fracture.

Interprosthetic humeral shaft fractures involving shoulder and elbow arthroplasty can be difficult to manage surgically, both due to fracture and patient characteristics. Adequate fixation can be difficult, given the intramedullary nature of the adjacent implants. Careful attention must be paid to regional anatomy, and care must be taken to not damage the radial or ulnar nerve during dissection and mobilization of the fracture, especially if scar tissue exists from multiple previous surgeries. Finally, fixation strategies must be used to gain stability in areas where there is a cement mantle or well-fixed intramedullary stem to impart the stability required for adequate healing and postoperative mobilization. Biologic augmentation is often used as well, given the relatively poor biologic environment for bone healing. We review our technique for operative fixation of a patient with a humeral shaft fracture between a cemented shoulder hemiarthroplasty and total elbow arthroplasty.

Periprosthetic Infections of the Shoulder: Diagnosis and Management.

The use of shoulder arthroplasty is continuing to expand. Periprosthetic joint infection of the shoulder is a devastating complication occurring in approximately 1% of cases. The most common organisms responsible for the infection are Cutibacterium acnes (formerly Propionibacterium acnes) (∼39%) and coagulase-negative Staphylococcus (∼29%). Evaluation of patients includes history and physical examination, serologic testing, imaging, possible joint aspiration, and tissue culture. Diagnosing infections caused by lower virulence organisms (eg, C acnes) poses a challenge to the surgeon because traditional diagnostic tests (erythrocyte sedimentation rate, C-reactive protein, and joint aspiration) have a low sensitivity due to the lack of an inflammatory response. Periprosthetic joint infections of the shoulder due to Staphylococcus aureus and other highly virulent organisms are often easy to diagnose and are usually treated with two-stage revisions. However, for infections with C acnes and coagulase-negative Staphylococcus, single- and two-stage revision surgeries have shown similar ability to clear the infection. Unexpected positive cultures for C acnes during revision surgery are not uncommon; the proper management is still under investigation and remains a challenge.

Reduced Time to Positive Cutibacterium acnes Culture Utilizing a Novel Incubation Technique: A Retrospective Cohort Study.

INTRODUCTION: Cutibacterium acnes (C. acnes) is a common pathogen in postoperative shoulder infections. The purpose of this study was to evaluate the time to positive cultures for C. acnes and compare our experience before and after implementation of a regulated anaerobic chamber system. We hypothesized that this would reduce the time to identify positive cultures. METHODS: This was a retrospective review of 34 patients with cultures obtained from the shoulder that were positive for C. acnes. The time until positive result was evaluated before and after implementation of a regulated anaerobic incubation chamber. RESULTS: Following implementation of the regulated anaerobic incubation chamber, the time until C. acnes culture growth significantly decreased from 6.5 days (range 3-10 days) to 4.9 days (range 2.75-10 days) (mean difference: 1.6 days, 95% confidence interval: 1.06-2.66 days; P = .002). True infections had a significantly shorter time to positive culture compared to contaminants (5.5 vs 6.8 days, respectively, P = .003). Increased number of positive culture specimens correlated with a shorter time to positivity (Spearman rank = -0.58, P = .007). CONCLUSION: Improved anaerobic culture protocols and techniques may lead to greater accuracy and earlier diagnosis and initiation of treatment of postoperative shoulder infections.