Editorial Commentary: Ceiling Effects Are a Limitation of Frequently Used Patient-Reported Outcomes Measures Used to Assess Shoulder Function: Appropriate Selection of Shoulder Patient-Reported Outcomes Measures Is Required-Especially in Athletes.

Ceiling effects (CEs) are a major limitation of frequently used patient-reported outcomes measures (PROMs) in the assessment of shoulder function. It is generally considered that a CE may be present when the best possible score for a given PROM is achieved by at least 15% of the study population. When a CE occurs, it typically indicates that the scoring criteria are relatively easy and therefore may not reliably capture greater levels of patient function. This is a particular problem with the use of activities of daily living-oriented PROMs in the evaluation of athletic patients because they can still score highly, despite limitations in athletic shoulder function. When a CE is present, it can result in failure to determine the true efficacy of a procedure, limited responsiveness to change, and furthermore if a subsequent comparison of 2 groups of patients is undertaken, it may produce similar results despite meaningful differences between them. It is important to recognize that CEs are common and have important consequences but that careful selection of PROMs adapted to the characteristics of the study population and the specific research question can help to mitigate these issues.

Editorial Commentary: The Minimal Clinically Important Difference Is Less Important Than It Sounds: Patients Seek to Achieve Substantial Clinical Benefits and Not Minimally Perceptible Improvements When They Undergo Arthroscopic Surgery.

The minimal clinically important difference (MCID) is a frequently reported metric for describing within-patient improvement in patient-reported outcome measures (PROMs). It was originally defined by Jaeschke et al. as "the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient's management." The latter part of this statement is often omitted, and this results in a loss of the originally intended value through lack of sufficient clinical importance to change management. Other pitfalls in the use of the MCID include that they are population- and condition-specific. As such, MCIDs lack external validity and cannot easily be extrapolated from one study to another. Furthermore, broadly different values can be obtained depending on the calculation method used. This makes the MCID an unhelpful metric when seeking to understand the true efficacy of a given intervention. The Food and Drug Administration recommends anchor-based methodologies (which take into account patient perception), over distribution-based methods (which are purely statistical and do not account for clinical meaningfulness to patients). Regardless, it should be noted that even anchor-based methodologies are susceptible to statistical bias, and measures are apt to be influenced by the regression to mean phenomena, where the value of the preintervention scores and their relationship to postintervention scores can bias estimates of the MCID. Finally, when using MCIDs, one must consider that they are a low bar. This means that patients do not undergo treatment to achieve minimally perceptible clinical improvements; instead, they undergo treatment with the hope of achieving substantial clinical benefit or a patient acceptable symptom state, and so these are more appropriate individual-level metrics to consider when evaluating clinically meaningful outcomes of treatment.

Recommended Requirements and Essential Elements for Proper Reporting of the Use of Artificial Intelligence Machine Learning Tools in Biomedical Research and Scientific Publications.

Essential elements required for proper use of artificial intelligence machine learning tools in biomedical research and scientific publications include (1) explanation justifying why a machine learning approach contributes to the purpose of the study; (2) description of the adequacy of the data (input) to produce the desired results (output); (3) details of the algorithmic (i.e., computational) approach including methods for organizing the data (preprocessing); the machine learning computational algorithm(s) assessed; on what data the models were trained; the presence of bias and efforts to mitigate these effects; and the methods for quantifying the variables (features) most influential in determining the results (e.g., Shapley values); (4) description of methods, and reporting of results, quantitating performance in terms of both model accuracy and model calibration (level of confidence in the model's predictions); (5) availability of the programming code (including a link to the code when available-ideally, the code should be available); (6) discussion of model internal validation (results applicable and sensitive to the population investigated and data on which the model was trained) and external validation (were the results investigated as to whether they are generalizable to different populations? If not, consideration of this limitation and discussion of plans for external validation, i.e., next steps). As biomedical research submissions using artificial intelligence technology increase, these requirements could facilitate purposeful use and comprehensive methodological reporting.

Editorial Commentary: Regression Modeling and Nomograms in Biomedical Research Are Valuable Decision-Making Tools When Externally Validated and Well Maintained.

The mathematical formulas underpinning biostatistical modeling in medical research can be complicated. Nomograms are pictoral tools showing a graphical solution of a formula in which all variables in the formula can be read off the diagram. Nomograms can be used to simplify the calculation of risk of recurrence of injuries or disease. Although nomograms can be valuable, external validation is required (of all models) to ensure accuracy outside of the original population, because variation in patient populations, activities, and risk behaviors outside of the patient data used in the original analysis may deteriorate model performance (external validity). A model also needs to be maintained over time to ensure continued accuracy as populations and activities change. A model that fails to keep up will eventually have its accuracy and clinical utility fade. An externally validated, well-maintained model can be a valuable tool for patient counseling and decision-making.

Editorial Commentary: The Difficulties of Assessing Return to Play and Return to Performance After Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament (UCL) tears have moved from a career-ending injury to one in which success is almost expected from reconstruction. In reality, however, success from a UCL reconstruction is not guaranteed. As we have attempted to assess the true success rate of UCL reconstructions, we have also learned the difficulties of this assessment. Rates of return to sport after UCL reconstruction vary by level of play, the primary or revision status of the repair, along with the specific surgical techniques performed, the chronicity of the tear, the rehabilitation protocols associated with the surgery, and more. Return to sport is difficult to assess, as high school, collegiate, and even professional careers can be variable and there are no standard definitions of "returning to play." These variables also affect our assessments of performance after UCL reconstruction. Decisions for UCL reconstructions and appropriate counseling of patients regarding the likelihood of success currently remain an individual process.

Disaggregation of Medical Research Data Reveals Outcome Differences in Demographic Groups and Presents Opportunity to Improve Patient Care.

Disaggregation, in the medical literature, means separation into demographic groups. This results in an opportunity to discover differences in outcomes by group, which could improve future treatments and provide outcome data, by group, that could be included in future systematic reviews. In research, the term disaggregation is most often used in reference to addressing inequities. We support the Sex and Gender Equity Research (SAGER) guidelines and encourage authors to examine how sex and gender are taken into account in their study and ensure adequate representation by sex and gender. (We respect that not all studies can or are designed to capture data by sex and gender, and that gender is "complex" and "fluid"). Disaggregation is encouraged, when possible, for other demographic variables allowing evaluation of all marginalized (as well as nonmarginalized) populations, so that we can better care for patients.

Editorial Commentary: Utility of Patient-Reported Outcome Threshold Scores to Estimate Patient Satisfaction: 'Let's Ask the Patient!'

The reporting and analysis of patient-reported outcome measures have come a long way. Since the concept of the minimally clinically important difference was first introduced in 1989, threshold scores have grown to include substantial clinical benefit and patient acceptable symptomatic state (PASS). The initial motivation for developing these thresholds was rooted in separating clinical significance from statistical. These thresholds provide insight into the relationship between scores on patient-reported outcome measures (PROM) and patient-reported improvement and satisfaction. It follows that in order to evaluate PROM scores, the best method for deriving the threshold typically uses an anchor-based methodology, i.e., "ask the patient." Specifically, patients are asked how much change they've experienced and whether they consider their current state to be satisfactory. The responses to these questions are compared with the scores on PROMs to find outcome thresholds that best separate patients who reported no improvement from those who reported minimal improvement, substantial improvement, and satisfaction with their current state of health (PASS). The PASS is of particular importance as it speaks to what arguably matters most to patients-a satisfactory state of health. Finally, viewing the PASS from the perspective of variation from study to study rather than as a uniform classifier is needed to make use of the growing number of papers reporting these thresholds. Examining differences in PASS values across papers can provide insight into how well PROM scores reflect patient satisfaction in different settings.

Editorial Commentary: The Statistical Fragility Index of Medical Trials Is Low By Design: Critical Evaluation of Confidence Intervals Is Required.

The Fragility Index (FI) provides the number of patients whose outcome would need to have changed for the results of a clinical trial to no longer be statistically significant. Although it's a well-intended and easily interpreted metric, its calculation is based on reversing a significant finding and therefore its interpretation is only relevant in the domain of statistical significance. Its interpretation is only relevant in the domain of statistical significance. A well-designed clinical trial includes an a priori sample size calculation that aims to find the bare minimum of patients needed to obtain statistical significance. Such trials are fragile by design! Examining the robustness of clinical trials requires an estimation of uncertainty, rather than a misconstrued, dichotomous focus on statistical significance. Confidence intervals (CIs) provide a range of values that are compatible with a study's data and help determine the precision of results and the compatibility of the data with different hypotheses. The width of the CI speaks to the precision of the results, and the extent to which the values contained within have potential to be clinically important. Finally, one should not assume that a large FI indicates robust findings. Poorly executed trials are prone to bias, leading to large effects, and therefore, small P values, and a large FI. Let's move our future focus from the FI toward the CI.

Biologic Adjuvants to Rotator Cuff Repairs Induce Anti-inflammatory Macrophage 2 Polarization and Reduce Inflammatory Macrophage 1 Polarization In Vitro.

PURPOSE: To examine the effect of various biologic adjuvants on the polarization of macrophages in an in vitro model for rotator cuff tears. METHODS: Tissue was harvested from 6 patients undergoing arthroscopic rotator cuff repair. An in vitro model of the supraspinatus and subacromial bursa was created and treated with control, platelet-rich plasma (PRP), autologous activated serum (AAS), or a combination of PRP+AAS. The effect of treatment on macrophage polarization between M1 proinflammatory macrophages or M2 anti-inflammatory macrophages was measured using gene expression, protein expression, flow cytometry, and nitric oxide production. RESULTS: Tendon and bursa treated with PRP, AAS, and PRP+AAS significantly decreased the gene expression of M1 markers interleukin (IL)-12 and tumor necrosis factor-alpha while significantly increasing the expression of M2 markers arginase, IL-10, and transforming growth factor-ß (P < .05) compared with treatment with control. Enzyme-linked immunosorbent assay analysis of protein production demonstrated that, compared with control, coculture treated with PRP, AAS, and PRP+AAS significantly decreased markers of M1-macrophages (IL-6, IL-12, and tumor necrosis factor-alpha) while significantly increasing the expression of markers of M2-macrophages (arginase, IL-10, and transforming growth factor-beta) (P < .05). Flow cytometry analysis of surface markers demonstrated that compared with control, tendon and bursa treated with PRP, AAS, and PRP+AAS significantly decreased markers of M1-macrophages (CD80, CD86, CD64, CD16) while significantly increasing the expression of markers of M2-macrophages (CD163 and CD206) (P < .05). Treatment of the coculture with PRP, AAS, and PRP+AAS consistently demonstrated a decrease in nitric oxide production (P < .05) compared with control. AAS and PRP+AAS demonstrated an increased macrophage shift to M2 compared with PRP alone, whereas there was not as uniform of a shift when comparing PRP+AAS with AAS alone. CONCLUSIONS: In an in vitro model of rotator cuff tears, the treatment of supraspinatus tendon and subacromial bursa with PRP, AAS, and PRP+AAS demonstrated an increase in markers of anti-inflammatory M2-macrophages and a concomitant decrease in markers of proinflammatory M1-macrophages. AAS and PRP+AAS contributed to a large shift to macrophage polarization to the anti-inflammatory M2 compared with PRP. CLINICAL RELEVANCE: The mechanism of biologic adjuvant effects on the rotator cuff remains poorly understood. This study suggests that they may contribute to polarization of macrophages for their proinflammatory (M1) state to the anti-inflammatory (M2) state.

Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review.

PURPOSE: To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up. METHODS: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I2. RESULTS: Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%). CONCLUSION: Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Human Rotator Cuff Tears Reveal an Age-Dependent Increase in Markers of Cellular Senescence and Selective Removal of Senescent Cells With Dasatinib + Quercetin Increases Genetic Expression of COL1A1 In Vitro.

PURPOSE: To quantify cellular senescence in supraspinatus tendon and subacromial bursa of humans with rotator cuff tears and to investigate the in vitro efficacy of the senolytic dasatinib + quercetin (D+Q) to eliminate senescent cells and alter tenogenic differentiation. METHODS: Tissue was harvested from 41 patients (mean age, 62 years) undergoing arthroscopic rotator cuff repairs. In part 1 (n = 35), senescence was quantified using immunohistochemistry and gene expression for senescent cell markers (p16 and p21) and the senescence-associated secretory phenotype (SASP) (interleukin [IL] 6, IL-8, matrix metalloproteinase [MMP] 3, monocyte chemoattractant protein [MCP] 1). Senescence was compared between patients <60 and ≥60 years old. In part 2 (n = 6) , an in vitro model of rotator cuff tears was treated with D+Q or control. D+Q, a chemotherapeutic and plant flavanol, respectively, kill senescent cells. Gene expression analysis assessed the ability of D+Q to kill senescent cells and alter markers of tenogenic differentiation. RESULTS: Part 1 revealed an age-dependent significant increase in the relative expression of p21, IL-6, and IL-8 in tendon and p21, p16, IL-6, IL-8, and MMP-3 in bursa (P < .05). A significant increase was seen in immunohistochemical staining of bursa p21 (P = .028). In part 2, D+Q significantly decreased expression of p21, IL-6, and IL-8 in tendon and p21 and IL-8 in bursa (P < .05). Enzyme-linked immunosorbent assay analysis showed decreased release of the SASP (IL-6, MMP-3, MCP-1; P = .002, P = .024, P < .001, respectively). Tendon (P = .022) and bursa (P = .027) treated with D+Q increased the expression of COL1A1. CONCLUSIONS: While there was an age-dependent increase in markers of cellular senescence, this relationship was not consistently seen across all markers and tissues. Dasatinib + quercetin had moderate efficacy in decreasing senescence in these tissues and increasing COL1A1 expression. CLINICAL RELEVANCE: This study reveals that cellular senescence may be a therapeutic target to alter the biological aging of rotator cuffs and identifies D+Q as a potential therapy.

Novel 3D MRI-Based Volumetric Assessment of Rotator Cuff Musculature Demonstrates Stronger Correlation with Preoperative Functional Status When Compared to the Goutallier Grading Scheme.

BACKGROUND: The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3D-magnetic resonance imaging (MRI) volumetric scores (VS) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to: (1) Describe the correlation between GC and VS for supraspinatus changes in RC tears, (2) Characterize the chronicity of RC tears using the battery of 12 VS measurements, and (3) Compare GC and VS to determine which method most closely corresponds with preoperative patient reported outcome measures (PROMs). METHODS: Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VS included fat infiltration (FIS), muscle size (MSS) and relative volume contribution (RCS) for each RC muscle. Backwards linear regression was performed to compare GC stage with preoperative PROMIS PF/PI to determine which VS measurement most closely correlated with preoperative PROMs. RESULTS: Eighty-two patients underwent RC repair (mean age 55±8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, p < 0.001); strong negative correlations were observed between MSS (r = -0.800, p < 0.001) and RCS (r = -0.745, p < 0.001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, p = 0.343) and PI (r = -0.071, p = 0.528). On multivariate analysis, subscapularis MSS (beta > 0, p = 0.064) was a positive predictor, and subscapularis FIS (beta < 0, p = 0.137), teres minor MSS (beta < 0, p = 0.141) and FIS (beta < 0, p = 0.070) were negative predictors of preoperative PF (r = 0.343, p = 0.044); while supraspinatus MSS (beta > 0, p = 0.009) and FIS (beta > 0, p = 0.073), teres minor FIS (beta > 0, p = 0.072) and subscapularis FIS (beta > 0, p = 0.065) were positive predictors of preoperative PI (r = 0.410, p = 0.006). CONCLUSION: Although gold standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VS showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Elliptical and spherical heads show similar obligate glenohumeral translation during axial rotation in total shoulder arthroplasty.

BACKGROUND: Elliptical shape humeral head prostheses have been recently proposed to reflect a more anatomic shoulder replacement. However, its effect on obligate glenohumeral translation during axial rotation compared to a standard spherical head is still not well understood. The purpose of the study was to compare obligate humeral translation during axial rotation using spherical and elliptical shaped humeral head prostheses. It was hypothesized that the spherical head design would show significantly more obligate translation when compared to the elliptical design. METHODS: Six fresh-frozen cadaveric shoulders were utilized for biomechanical testing of internal (IR) and external (ER) rotation at various levels of abduction (0°, 30°, 45°, 60°) with lines of pull along each of the rotator cuff muscles. Each specimen underwent the following three conditions: (1) native; total shoulder arthroplasty (TSA) using (2) an elliptical and (3) spherical humeral head implant. Obligate translation during IR and ER was quantified using a 3-dimensional digitizer. The radius of curvature of the superoinferior and anteroposterior dimensions of the implants was calculated across each condition. RESULTS: Posterior and inferior translation as well as compound motion of spherical and elliptical heads during ER was similar at all abduction angles (P > 0.05, respectively). Compared to the native humeral head, both implants demonstrated significantly decreased posterior translation at 45° (elliptical: P = 0.003; spherical: P = 0.004) and 60° of abduction (elliptical: P < 0.001; spherical: P < 0.001). During internal rotation at 0° abduction, the spherical head showed significantly more compound motion (P = 0.042) compared to the elliptical head. The spherical implant also demonstrated increased anterior translation and compound motion during internal rotation at 60° abduction (P < 0.001) compared to the resting state. This difference was not significant for the native or elliptical head design at this angle (P > 0.05). CONCLUSION: In the setting of TSA, elliptical and spherical head implants showed similar obligate translation and overall compound motion during axial rotation. A gained understanding of the consequences of implant head shape in TSA may guide future surgical implant choice for better recreation of native shoulder kinematics and potentially improved patient outcomes. LEVEL OF EVIDENCE: Controlled Laboratory Study.

Guidelines for Proper Reporting of Clinical Significance, Including Minimal Clinically Important Difference, Patient Acceptable Symptomatic State, Substantial Clinical Benefit, and Maximal Outcome Improvement.

Patient-reported outcome measures (PROM) need to be responsive, reliable, and validated for the specific condition or treatment. PROMs also need to exhibit a dose-dependent response across a diverse patient population, unlimited by floor and ceiling effects. Statistically significant differences between compared groups might not always represent clinically important differences. Measures of clinical significance reflect a spectrum of patient satisfaction after an intervention. A noticeable difference to the patient is assessed with minimal clinically important difference (MCID), patient satisfaction by patient acceptable symptomatic state (PASS), and a "considerable" improvement by substantial clinical benefit (SCB). Clinical relevance measured by these clinically significant outcomes (CSO) are limited by ceiling effects. Maximal outcome improvement (MOI) might more accurately account for patients with higher baseline or preoperative PROMs, thereby limiting ceiling effects. The acts of measuring (and reporting) patient-centered endpoints may actually be of greater importance than collecting objective clinician-measured data. As the old surgeon's aphorism goes, "nothing ruins good results like good follow-up."

Editorial Commentary: Knowledge is Power: A Primer for Machine Learning.

Machine learning (ML) has become an increasingly common statistical methodology in medical research. In recent years, ML techniques have been used with greater frequency to evaluate orthopaedic data. ML allows for the creation of adaptive predictive models that can be applied to clinical patient outcomes. However, ML models for predicting clinical or safety outcomes may be made available online so that physicians may apply these models to their patients to make predictions. If the algorithms have not been externally validated, then the models are not likely to generalize, and their predictions will suffer from inaccuracy. This is especially important to bear in mind because the recent increase in ML papers in the medical literature includes publications with fundamental flaws.

Editorial Commentary: Blood Flow Restriction Therapy Prior to Anterior Cruciate Ligament Reconstruction: Small Effects Require Accurate Measurements.

A recent research study showed that blood flow restriction (BFR) therapy was safe and well tolerated but failed to demonstrate efficacy as a modality that provides greater gains in quadriceps strength when added to a standard home program in patients awaiting anterior cruciate ligament (ACL) reconstruction. Despite employing a validated method of measurement, the results were highly variable, indicating the need for measurements with sufficient accuracy to detect the small, but potentially meaningful, gains in quadriceps strength that's been attributed to BFR. The results inform future investigations of BFR prior to ACL surgery by demonstrating the need for accurate methods of measurements when the anticipated effects are small.

Location and Progression of Chondral Injuries at the Time of Revision ACL Surgery Varies by Sex.

PURPOSE: To quantify progression of chondral and meniscal injuries between primary and revision anterior cruciate ligament (ACL) surgery. METHODS: Patients who underwent both index and revision ACL reconstruction between 2000 and 2020 at our institution were identified, and dates of injury and surgery, demographics, and clinical data were obtained from operative reports. Outerbridge grade was recorded in each compartment, along with presence and location of meniscal injury. The frequency of each injury between first and second cases was calculated. Differences in injury and progression were compared over time as well as between patient sex and age. RESULTS: The study included 189 patients (96 female, 93 male). Age at first surgery was 31.7 ± 13.2 years. Mean time to second injury was 3.3 ± 3.0 years. In total, 116 patients had a new or previous chondral injury (odds ratio, 1.6; 95% CI, 1.2-2.1). The medial femoral condyle (31%) and the patella (21%) accounted for the highest proportion of new injury to articular surfaces, whereas new injury to menisci was comparable between the medial (25%) and lateral (23%) meniscus. At the time of revision ACL reconstruction, females had a high prevalence of chondral injuries to the lateral compartment, whereas males had a high prevalence of chondral injury to the medial femoral condyle. The prevalence of new chondral injuries was comparable between sexes, with males having a slightly higher proportion. While time between surgeries, sex, and age had graphical evidence of moderating risk, the effects were small and imprecise. CONCLUSIONS: Revision ACL reconstruction carried a 1.6 increase in the odds for new or progressive chondral lesions in our cohort. At the time of revision, females had a relatively higher proportion of lateral-sided chondral injuries, whereas males had a relatively higher proportion of medial femoral condyle injuries. The greatest increase in the prevalence of new and progressive lesions was observed in the medial femoral condyle and trochlea. This progression appeared to be moderated by time between surgeries, patient sex, and age; however, the differences were small and imprecise. STUDY DESIGN: Level IV, therapeutic case series.

Is there value in the routine practice of discarding the incision scalpel from the surgical field to prevent deep wound contamination with Cutibacterium acnes? An update.

BACKGROUND: Cutibacterium acnes is the most common microbe implicated in periprosthetic infection in shoulder arthroplasty. We present an update of a previous pilot study in which we demonstrated the persistence of C acnes on the skin and contamination of the scalpel used for the initial skin incision despite a robust presurgical skin preparation protocol. METHODS: We collected a consecutive case series of patients undergoing primary or revision anatomic or reverse total shoulder arthroplasty performed by a single fellowship-trained surgeon at a tertiary referral hospital from November 2019 to December 2022. The scalpel blade used for the initial skin incision in each patient was swabbed, with cultures being held for 21 days according to a C acnes-specific protocol. Demographic data, medical comorbidities, surgical information, culture results, and infections were documented. RESULTS: We identified 100 patients (51 men and 49 women) who met the inclusion criteria (mean age, 66.91 years; age range, 44-93 years). Cultures returned positive findings for C acnes in 12 patients (12%), 11 of whom were men (odds ratio, 13.2; 95% confidence interval, 1.73-194.87). No association was found between positive culture findings and age, body mass index, medical comorbidities, or procedure type. No postoperative infections occurred in this patient cohort, and the patients will continue to be monitored for the development of infection. CONCLUSION: Despite stringent presurgical preparation and scrub protocols, a significant portion of patients undergoing shoulder arthroplasty have C acnes in culturable quantities on their skin at the time of incision. C acnes contamination is much more common in male patients. These findings should be taken into consideration regarding preventive measures such as discarding the initial scalpel and avoiding unnecessary dermal contact during the procedure.

Biomechanical evaluation of subscapularis peel repairs augmented with the long head of the biceps tendon for anatomic total shoulder arthroplasty.

BACKGROUND: Subscapularis failure is a troublesome complication following anatomic total shoulder arthroplasty (aTSA). Commonly discarded during aTSA, the long head of the biceps tendon (LHBT) may offer an efficient and cheap autograft for the augmentation of the subscapularis repair during aTSA. The purpose of this study was to biomechanically compare a standard subscapularis peel repair to 2 methods of subscapularis peel repair augmented with LHBT. METHODS: 18 human cadaveric shoulders (61 ± 9 years of age) were used in this study. Shoulders were randomly assigned to biomechanically compare subscapularis peel repair with (1) traditional single-row repair, (2) single row with horizontal LHBT augmentation, or (3) single row with V-shaped LHBT augmentation. Shoulders underwent biomechanical testing on a servohydraulic testing system to compare cyclic displacement, load to failure, and stiffness. RESULTS: There were no significant differences in the cyclic displacement between the 3 techniques in the superior, middle, or inferior portion of the subscapularis repair (P > .05). The horizontal (436.7 ± 113.3 N; P = .011) and V-shape (563.3 ± 101.0 N; P < .001) repair demonstrated significantly greater load to failure compared with traditional repair (344.4 ± 82.4 N). The V-shape repair had significantly greater load to failure compared to the horizontal repair (P < .001). The horizontal (61.6 ± 8.4 N/mm; P < .001) and the V-shape (62.8 ± 6.1; P < .001) repairs demonstrated significantly greater stiffness compared to the traditional repair (47.6 ± 6.2 N). There was no significant difference in the stiffness of the horizontal and V-shape repairs (P = .770). CONCLUSIONS: Subscapularis peel repair augmentation with LHBT autograft following aTSA confers greater time zero load to failure and stiffness when compared to a standard subscapularis peel repair.

Elliptical heads result in increased glenohumeral translation along with micro-motion of the glenoid component during axial rotation in total shoulder arthroplasty.

INTRODUCTION: Elliptical-shaped humeral head prostheses have recently been proposed to reflect a more anatomic shoulder replacement. However, its subsequent effect on micro-motion of the glenoid component is still not understood. MATERIALS AND METHODS: Six fresh-frozen, cadaveric shoulders (mean age: 62.7 ± 9.2 years) were used for the study. Each specimen underwent total shoulder arthroplasty using an anatomic stemless implant. At 15°, 30°, 45° and 60° of glenohumeral abduction, 50° of internal and external rotations in the axial plane were alternatingly applied to the humerus with both an elliptical and spherical humeral head design. Glenohumeral translation was assessed by means of a 3-dimensional digitizer. Micro-motion of the glenoid component was evaluated using four high-resolution differential variable reluctance transducer strain gauges, placed at the anterior, posterior, superior, and inferior aspect of the glenoid component. RESULTS: The elliptical head design showed significantly more micro-motion in total and at the superior aspect of glenoid component during external rotation at 15° (total: P = 0.004; superior: P = 0.004) and 30° (total: P = 0.045; superior: P = 0.033) of abduction when compared to the spherical design. However, during internal rotation, elliptical and spherical heads showed similar amounts of micro-motion at the glenoid component at all tested abduction angles. When looking at glenohumeral translation, elliptical and spherical heads showed similar anteroposterior and superoinferior translation as well as compound motion during external rotation at all tested abduction angles. During internal rotation, the elliptical design resulted in significantly more anteroposterior translation and compound motion at all abduction angles when compared to the spherical design (P < 0.05). CONCLUSION: In the setting of total shoulder arthroplasty, the elliptical head design demonstrated greater glenohumeral translation and micro-motion at the glenoid component during axial rotation when compared to the spherical design, potentially increasing the risk for glenoid loosening in the long term. LEVEL OF EVIDENCE: Controlled Laboratory Study.