Loss of IFN-γ Pathway Genes in Tumor Cells as a Mechanism of Resistance to Anti-CTLA-4 Therapy.

Antibody blockade of the inhibitory CTLA-4 pathway has led to clinical benefit in a subset of patients with metastatic melanoma. Anti-CTLA-4 enhances T cell responses, including production of IFN-γ, which is a critical cytokine for host immune responses. However, the role of IFN-γ signaling in tumor cells in the setting of anti-CTLA-4 therapy remains unknown. Here, we demonstrate that patients identified as non-responders to anti-CTLA-4 (ipilimumab) have tumors with genomic defects in IFN-γ pathway genes. Furthermore, mice bearing melanoma tumors with knockdown of IFN-γ receptor 1 (IFNGR1) have impaired tumor rejection upon anti-CTLA-4 therapy. These data highlight that loss of the IFN-γ signaling pathway is associated with primary resistance to anti-CTLA-4 therapy. Our findings demonstrate the importance of tumor genomic data, especially IFN-γ related genes, as prognostic information for patients selected to receive treatment with immune checkpoint therapy.

HiJAKing Immunotherapy-Resistant Melanoma for a Cure.

Immune checkpoint blockers (ICBs) have brought great promise to patients with advanced melanoma, a tumor type that was claimed largely incurable not long ago. However, therapeutic resistance to ICBs has limited their utility in the clinic. Here, we provide a commentary on recent research endeavors concerning ICB resistance in melanoma patients.

Proximal Humerus Fractures: Leave It Alone, Fix It, Replace It?

Proximal humerus fractures are common injuries that account for 10% of all fractures in the elderly. Several options are available for the management of proximal humerus fractures. Optimal treatment is based on the fracture pattern and the patient characteristics. Most of these fractures are minimally displaced and managed nonsurgically. Approximately 15% of proximal humerus fractures are comminuted, head-split, fracture-dislocation, or severely displaced, which make the best treatment option more challenging. Hemiarthroplasty is still a viable option in selected patients of these groups; however, advancements in locking plate designs and introduction of reverse total shoulder arthroplasty have led to better clinical outcome in meticulously selected patients. Nonetheless, the debate continues regarding the best management. It is important to discuss the best treatment options based on current literature.

Total hip arthroplasty after acetabular fractures in the older population: timing of intervention may improve patient outcomes.

PURPOSE: This study evaluates complication rates following treatment modalities of THA for acetabular fractures in the older population. METHODS: A national insurance database was used to identify acetabular fracture patients of age > 50 who underwent THA treatment within two years of fracture. Four subgroups were identified: primary THA < 2 months after injury (acute THA), primary THA > 2 months after injury (delayed THA), simultaneous ORIF and THA, and conversion THA after ORIF (THA after ORIF). A 3:1 match was performed between these subgroups and patients undergoing THA for non-fracture causes. Patients were matched based on age, gender and the diagnosis of diabetes, hypertension, obesity or tobacco use. Complication rates were compared, including hospital readmission, revision, infection and deep vein thrombosis (DVT). RESULTS: In total, 3807 patients met inclusion criteria and were matched with 11,421 controls. Compared to controls, acute THA and delayed THA patients had significantly increased rates of all complications (OR ranges 1.45 - 2.82, p < 0.001). Simultaneous ORIF and THA and THA after ORIF patients had significantly increased rates of revision, infection and DVT (OR ranges 1.76 - 3.96, p ranges < 0.001 - p = 0.031). Compared to delayed THA, acute THA patients had significantly higher rates of readmission (OR = 1.16, p = 0.021) and DVT (OR = 1.89, p < 0.001). CONCLUSION: Consistent with prior literature, THA after acetabular fracture is associated with higher complication rates than THA for non-fracture causes. Acute THA following acetabular fracture is also associated with higher rates of readmission and DVT than delayed THA.

De Quervain Tenosynovitis: An Evaluation of the Epidemiology and Utility of Multiple Injections Using a National Database.

PURPOSE: We hypothesized that repeat injections are associated with a decreased rate of success and that the success rate of injections correlates with patient comorbidities. METHODS: Using a commercially available insurance database, patients diagnosed with De Quervain tenosynovitis were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes and stratified by therapeutic interventions, including therapy, injections, and surgery, as well as comorbidities. Injection failure was defined as a patient receiving a repeat injection or subsequent surgical management. Success was defined as no further therapies identified after an intervention. RESULTS: From 2007 to 2017, 33,420 patients with a primary diagnosis of De Quervain tenosynovitis were identified. Women represented 77.5% (25,908) of the total and were 2.6 times more likely to be diagnosed than men. Black patients were more likely to be diagnosed than White patients. Black and White women were found to have the highest incidence (relative risk 3.4 and 2.3, respectively, compared with White men). Age was also significantly correlated with an increased risk of diagnosis of the condition, with a peak incidence at the age of 40-59 years (relative risk, 10.6). Diabetes, rheumatoid arthritis, lupus, and hypothyroidism were associated with an increased risk of diagnosis. Overall, 53.3% of the patients were treated with injections, 11.6% underwent surgery, and 5.2% underwent therapy. Treatment with a single injection was successful in 71.9% of the patients, with 19.7% receiving a repeat injection and 8.4% treated with surgery. The overall success rate of subsequent injections was 66.3% for the second injection and 60.5% for the third. The initial injection had a higher rate of success in diabetics than in nondiabetics; however, the difference (2%) was not clinically relevant. CONCLUSIONS: Although the success rate for the treatment of De Quervains tenosynovitis decreases with multiple injections, repeat injections have a high rate of success and are a viable clinical option. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Qualitative and Quantitative Anatomy of the Deep Radioulnar Ligaments' Insertion on Ulna: Cadaveric, Histologic, and MRI Study.

PURPOSE: To qualitatively and quantitatively analyze the anatomic features of the insertion of deep radioulnar ligaments (RULs) and provide an anatomic basis for further studies. METHODS: The anatomic features of deep RUL insertion were observed macroscopically in 26 cadaveric wrists, after which the size of the deep RUL footprint and distance from the center of the footprint to the ulnar-sided margin of articular cartilage of the ulnar head were each measured. Five specimens were analyzed histologically to examine the attachment of the RUL on the ulna. In addition, we evaluated 21 asymptomatic wrists from healthy volunteers using 3.0 T magnetic resonance imaging. RESULTS: The insertion of the deep RUL was located mainly on the radial aspect of the ulnar fovea from the foveal center to the articular cartilage. The footprint of the deep RUL appeared in 3 different shapes. The maximal width, length, and area of the footprint of the deep RUL were 3.7 (95% confidence interval [CI], 3.3-4.0) mm, 8.4 (95% CI, 7.9-8.9) mm, and 26.3 (95% CI, 23.4-29.1) mm2, respectively. Histologic analyses showed the attachment of the deep RUL on the radial wall of the fovea exhibited a direct insertion with typical 4-layer structures. The deep RUL fibers formed an acute angle with the distal component of the triangular fibrocartilage complex. CONCLUSIONS: The deep RUL was inserted on the radial side of the ulnar fovea and not the foveal center; it had direct insertion on the radial wall continuous with articular cartilage, and the fibers in the direct insertion formed an acute angle with the distal component of the triangular fibrocartilage complex. CLINICAL RELEVANCE: Understanding the quantitative anatomy of the deep RUL insertion may help guide surgeons to perform an anatomic foveal repair of the triangular fibrocartilage complex in its native footprint.

Chronic Preoperative Opioids Are Associated With Revision After Rotator Cuff Repair.

PURPOSE: We sought to clarify the relationship between chronic preoperative opioids and complications following rotator cuff repair. Specifically, we assessed revision, a definitive postoperative end point for surgical outcome. METHODS: This study used PearlDiver, a United States national insurance claims database. All patients undergoing rotator cuff repair from 2008 to 2018 were identified and stratified based on a minimum of 2 opioid prescriptions within the 6 months before surgery, with 1 prescription occurring within 0 to 3 months before surgery and a second prescription within 4 to 6 months before surgery. Univariate logistic regressions of risk factors were conducted, followed by multivariate analysis of comorbidities, including ongoing preoperative opioids, any preoperative nonsteroidal anti-inflammatory drug (NSAID) prescriptions, age, sex, diabetes, tobacco, and obesity. RESULTS: In total, 28,939 patients undergoing rotator cuff repair were identified, of whom 10,695 had opioid prescriptions within both 0 to 3 months and 4 to 6 months before index rotator cuff repair, whereas 18,244 had no opioid prescriptions within the 6-month preoperative period. In total, 977 (3.4%) patients underwent revision within 6 months, which increased to 1311 (4.5%) within 1 year of the index procedure. In the multivariate analysis controlling for age, preoperative NSAID prescriptions, tobacco, diabetes, obesity, and sex, we observed a significant association between chronic preoperative opioid prescriptions and rotator cuff repair revision (6-month odds ratio 1.12; P = .021, 1-year odds ratio 1.43; P < .001) following index procedure. CONCLUSIONS: We report increased rates of revision within both 6 months and 1 year in patients with prolonged preoperative opioid prescriptions. The opioid cohort had greater rates of preoperative NSAID use and tobacco use, which also were observed to be independent risk factors for revision at both timepoints. LEVEL OF EVIDENCE: III; Retrospective comparative study.

Pharmacologic Thromboprophylaxis Other Than Aspirin Is Associated With Increased Risk for Procedural Intervention for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare rates of procedural intervention for arthrofibrosis following anterior cruciate ligament reconstruction (ACLR) among patients who were not prescribed any pharmacologic thromboprophylaxis compared with patients who were prescribed aspirin and to patients who were prescribed other agents. METHODS: A search of a national insurance claims database was performed to identify all patients who underwent ACLR from 2007 to 2017 who were active within the database at a minimum of 6 months before and 18 months after their surgery. The primary outcome studied was a subsequent procedure for arthrofibrosis, manipulation under anesthesia, and lysis of adhesions (MUA/LOA). Patients who filled a prescription for aspirin, low-molecular weight heparin, direct factor Xa inhibitors, fondaparinux, and warfarin within 2 days after their surgery were included and those who filled a prescription within 3 months before surgery were excluded. Thromboprophylaxis status was defined as no thromboprophylaxis, aspirin, and any agent other than aspirin. Logistic regression analysis was performed to determine the association between prophylaxis status and MUA/LOA. RESULTS: Of the 14,081 patients in our final surgical population, 191 patients had MUA/LOA and 13,890 patients did not. In total, 499 patients were prescribed pharmacologic prophylaxis. Rates of MUA/LOA across groups were 1.3% in the group with no thromboprophylaxis, 1.9% in the group prescribed aspirin, and 4.3% in the group prescribed any agent other than aspirin. Only the group prescribed an agent other than aspirin was significantly associated with subsequent procedure for arthrofibrosis (odds ratio 2.6, 95% confidence interval 1.3-4.8, P = .004). CONCLUSIONS: Patients who were prescribed a pharmacologic agent other than aspirin had a 2.6 times greater likelihood of requiring a procedural intervention for arthrofibrosis following ACLR compared with patients who were not prescribed a thromboprophylaxis agent LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair.

PURPOSE: The goal of this study was to investigate trends in the United States for arthroscopic subacromial decompression (aSAD) and open SAD (oSAD) with and without rotator cuff repair (RCR) between 2010 and 2018. METHODS: The PearlDiver Mariner claims database was queried using CPT codes for open and arthroscopic subacromial decompression and rotator cuff repair. Patient cohorts were developed for those undergoing aSAD or oSAD between 2010 and 2018, then segmented by whether RCR was performed simultaneously. Annual incidence was analyzed, as were associated diagnosis codes, and concomitant shoulder-associated procedures performed on the same day. RESULTS: The PearlDiver Mariner dataset from 2010 to 2018 included 186,932 patients that underwent aSAD, while 9,263 patients underwent oSAD. The total incidence of aSAD declined from 118.0 to 71.3 per 100,000 (39.6% decrease) (P < .001). This change was due primarily to a decreasing incidence of aSAD performed without RCR, which declined from 66.3 to 25.5 per 100,000 (61.5% decrease) (P < .001). During the same period, the incidence of aSAD combined with RCR remained relatively stable, from 51.7 to 45.8 per 100,000 (11.5% decrease) (P = .27). The overall incidence of oSAD declined from 7.1 to 2.2 per 100,000 (68.1% decrease) (P < .001). CONCLUSIONS: The overall rate of aSAD has declined in recent years, primarily due to a large decrease in the incidence of aSAD without RCR as an isolated treatment for rotator cuff disorders. CLINICAL RELEVANCE: Prior studies have demonstrated a rising incidence of SAD; however, high-level clinical evidence and clinical practice guidelines have challenged its efficacy. It is important for orthopaedic surgeons to understand evolving national trends in management among their peers.

Correcting severe flexion contracture with fusiform capsulectomy of posterior capsule during total knee arthroplasty.

PURPOSE: This study aimed to evaluate the safety and efficacy of fusiform capsulectomy of posterior capsule in correcting severe flexion contracture during total knee arthroplasty (TKA). METHODS: A retrospective analysis was performed in the patients who had preoperative severe flexion contracture (> 30 degrees) prior to TKA and received fusiform capsulectomy of posterior capsule during TKA between December 2013 and November 2018. Range of motion (ROM), knee functional score, forgotten joint score (FJS), post-operative complications, and radiographic results were collected and evaluated. RESULT: Twenty patients (32 knees) were enrolled in this study. The mean duration of follow-up was 27.19 ± 15.92 months. The flexion contracture improved from pre-operative 37.69 ± 11.79° to post-operative 5.78 ± 4.44° (p < 0.001), and ROM increased from pre-operative 63.50 ± 21.74° to post-operative 97.88 ± 13.20° (p < 0.001). KSS clinical score increased from pre-operative 32.94 ± 11.03 to post-operative 82.34 ± 10.73 (p < 0.001), and KSS function score increased from pre-operative 28.97 ± 18.43 to post-operative 68.75 ± 15.96 (p < 0.001). The post-operative FJS was 76.08 ± 2.14. There was no implant loosening, infection, obvious haematoma formation, resultant instability, neurovascular complications, or revision for any reasons in the cohort until the last follow-up. CONCLUSIONS: The technique of fusiform capsulectomy of posterior capsule to correct the severe flexion contracture during primary TKA is safe and effective and could provide good short-term results.

Evaluation of rotator cuff abduction moment arms for superior capsular reconstruction and reverse total shoulder arthroplasty.

PURPOSE: The rotator cuff (RC) muscles contribute to dynamic stability and rotational actions of the glenohumeral joint. Moment arm can be used to demonstrate the potential work a muscle contributes to a musculoskeletal joint rotation. This study aimed to understand the moment arm contributions of the RC muscles and explore changes following a complete supraspinatus tear treated with either superior capsular reconstruction (SCR) or reverse total shoulder arthroplasty (rTSA). METHODS: Five fresh-frozen cadaveric specimens were prepared and mounted in an apparatus where each intact RC muscle was held in tension with a line of action toward its origin on the scapula. Mean moment arms for each muscle were determined experimentally based on Optotrak data collected during cadaveric shoulder arm abduction. RESULTS: Using ANOVA testing, our analysis demonstrated significant differences (p < 0.001) in infraspinatus and teres minor moment arms after rTSA compared to the intact shoulder model. After SCR, significant differences (p < 0.001) were seen in teres minor, with these differences being statistically similar to the changes seen in teres minor after rTSA. Subscapularis showed no significant difference in moment arm values between the models (p = 0.148). CONCLUSION: Our results illustrate that mean moment arms were preserved in the RC muscles after complete supraspinatus tear. This study also shows evidence that subscapularis function may be maintained after SCR or rTSA. After SCR, infraspinatus may maintain similar abduction ability compared to the anatomical shoulder, while teres minor ability may increase. Infraspinatus may have decreased abduction ability after rTSA while teres minor may have increased ability.

Bridging Radiotherapy to Immunotherapy: The IFN-JAK-STAT Axis.

The unprecedented successes of immunotherapies (IOs) including immune checkpoint blockers (ICBs) and adoptive T-cell therapy (ACT) in patients with late-stage cancer provide proof-of-principle evidence that harnessing the immune system, in particular T cells, can be an effective approach to eradicate cancer. This instills strong interests in understanding the immunomodulatory effects of radiotherapy (RT), an area that was actually investigated more than a century ago but had been largely ignored for many decades. With the "newly" discovered immunogenic responses from RT, numerous endeavors have been undertaken to combine RT with IOs, in order to bolster anti-tumor immunity. However, the underlying mechanisms are not well defined, which is a subject of much investigation. We therefore conducted a systematic literature search on the molecular underpinnings of RT-induced immunomodulation and IOs, which identified the IFN-JAK-STAT pathway as a major regulator. Our further analysis of relevant studies revealed that the signaling strength and duration of this pathway in response to RT and IOs may determine eventual immunological outcomes. We propose that strategic targeting of this axis can boost the immunostimulatory effects of RT and radiosensitizing effects of IOs, thereby promoting the efficacy of combination therapy of RT and IOs.

Are Comorbidities Affecting Rotator Cuff Repair Outcomes? A Retrospective Review of Postoperative Costs and complications.

Our study examines the effect of comorbidities on rotator cuff repair (RCR) postoperative costs and complication rates. A retrospective review of patients receiving RCRs from 2008-2016 using the PearlDiver database was performed. We evaluated the effect of major comorbidities on postoperative costs and complications within one year of surgery. In total, 8,747 patients underwent RCR. Patients with no comorbidities had a 6-month and 12-month postoperative cost of $3,534 and $3,853, respectively. Patients with one comorbidity had 6-month postoperative costs ranging from $2,623 to $3,466 and 1-year postoperative costs ranging from $2,992 to $5,906. Patients with 3+ comorbidities receiving arthroscopic RCR had the highest complication rates at 1-, 3- and 6-month intervals (11.8%, 19.7% and 26.8%, respectively) compared to those with no comorbidities (8.1% [p = 0.139], 12.7% [p = 0.022] and 15.9% [p = 0.001], respectively). Patients with isolated comorbidities likely require similar healthcare utilization to those without, but patients with 3+ comorbidities risk greater complications and higher post-operative costs. (Journal of Surgical Orthopaedic Advances 30(1):024-029, 2021).

Signaling by the phosphatase MKP-1 in dendritic cells imprints distinct effector and regulatory T cell fates.

Naive T cells respond to antigens by differentiating into effector and regulatory lineages. Whereas the roles of T cell-intrinsic pathways have been extensively studied, how T cell lineage choices are controlled by innate immune signals remains elusive. Here we report that dendritic cell (DC)-expressed phosphatase MKP-1, a negative regulator of the MAP kinases, programmed reciprocal T helper 1 (Th1) and Th17 cell differentiation by modulating IL-12-STAT4 and IL-6-STAT3 axes and cytokine receptor expression at the DC-T cell interface. MKP-1 was regulated by innate recognition signals and its deficiency disrupted antimicrobial responses and promoted T cell-mediated inflammation. Moreover, MKP-1 inhibited induction of regulatory T cells by downregulating TGF-ß2 production from DCs. Our findings identify a regulatory circuit linking MKP-1 signaling in DCs, production of polarizing cytokines, and integration of DC-derived signals in responding T cells, that bridges innate and adaptive immunity to coordinate protective immunity and immunopathology.

The transcription factor Myc controls metabolic reprogramming upon T lymphocyte activation.

To fulfill the bioenergetic and biosynthetic demand of proliferation, T cells reprogram their metabolic pathways from fatty acid ß-oxidation and pyruvate oxidation via the TCA cycle to the glycolytic, pentose-phosphate, and glutaminolytic pathways. Two of the top-ranked candidate transcription factors potentially responsible for the activation-induced T cell metabolic transcriptome, HIF1α and Myc, were induced upon T cell activation, but only the acute deletion of Myc markedly inhibited activation-induced glycolysis and glutaminolysis in T cells. Glutamine deprivation compromised activation-induced T cell growth and proliferation, and this was partially replaced by nucleotides and polyamines, implicating glutamine as an important source for biosynthetic precursors in active T cells. Metabolic tracer analysis revealed a Myc-dependent metabolic pathway linking glutaminolysis to the biosynthesis of polyamines. Therefore, a Myc-dependent global metabolic transcriptome drives metabolic reprogramming in activated, primary T lymphocytes. This may represent a general mechanism for metabolic reprogramming under patho-physiological conditions.

Preoperative lumbar epidural steroid injections administered within 6 weeks of microdiscectomy are associated with increased rates of reoperation.

PURPOSE: Lumbar epidural steroid injections (LESIs) are widely utilized for back pain. However, as studies report adverse effects from these injections, defining a safe interval for their use preoperatively is necessary. We investigated the effects of preoperative LESI timing on the rates of recurrent microdiscectomy. METHODS: This study utilized the PearlDiver national insurance claims database. Microdiscectomy patients were stratified by the timing of their most recent LESI prior to surgery into bimonthly cohorts (0-2 months, 2-4 months, 4-6 months). This first cohort was further stratified into biweekly cohorts (0-2 weeks, 2-4 weeks, 4-6 weeks, 6-8 weeks). The 6-month reoperation rate was assessed and compared between each injection cohort and a control group of patients with no injections within 6 months before surgery. Univariate analyses of reoperation were conducted followed by multivariate analyses controlling for risk factors where appropriate. RESULTS: A total of 12,786 microdiscectomy patients were identified; 1090 (8.52%) received injections within 6 months before surgery. We observed a significant increase in the 6-month reoperation rates in patients who received injections within 6 weeks prior to surgery (odds ratio [OR] 1.900, 1.218-2.963; p = 0.005) compared to control. No other significant differences were observed. DISCUSSION: In this study, microdiscectomy performed within 6 weeks following LESIs was associated with a higher risk of reoperation, while microdiscectomy performed more than 6 weeks from the most recent LESI demonstrated no such association with increased risk. Further research into the interaction between LESIs and recurrent disk herniation is necessary.

Gfi1-Foxo1 axis controls the fidelity of effector gene expression and developmental maturation of thymocytes.

Double-positive (DP) thymocytes respond to intrathymic T-cell receptor (TCR) signals by undergoing positive selection and lineage differentiation into single-positive (SP) mature cells. Concomitant with these well-characterized events is the acquisition of a mature T-cell gene expression program characterized by the induction of the effector molecules IL-7Rα, S1P1, and CCR7, but the underlying mechanism remains elusive. We report here that transcription repressor Growth factor independent 1 (Gfi1) orchestrates the fidelity of the DP gene expression program and developmental maturation into SP cells. Loss of Gfi1 resulted in premature induction of effector genes and the transcription factors forkhead box protein O1 (Foxo1) and Klf2 in DP thymocytes and the accumulation of postselection intermediate populations and accelerated transition into SP cells. Strikingly, partial loss of Foxo1 function, but not restored survival fitness, rectified the dysregulated gene expression and thymocyte maturation in Gfi1-deficient mice. Our results establish the Gfi1-Foxo1 axis and the transcriptional circuitry that actively maintain DP identity and shape the proper generation of mature T cells.

Trans-coracoacromial Ligament Glenohumeral Injection With Arthroscopic Confirmation.

PURPOSE: To arthroscopically evaluate the trans-coracoacromial ligament glenohumeral (GH) injection technique by understanding intra-articular needle-tip placement and potential misplacement and complications. METHODS: The technique relies on the palpation of 3 bony landmarks: anterolateral corner of the acromion, superolateral border of the coracoid tip, and curved depression of the distal clavicle. The skin entry site lies on the line connecting the curved depression of the distal clavicle and superolateral border of the coracoid tip, two-thirds of the way from the former and one-third of the way from the latter. The direction of the needle is perpendicular to the triangle formed by the 3 bony landmarks. The technique is used to insufflate the GH joint at the start of shoulder arthroscopy procedures with patients in the beach-chair position. Saline solution is injected, and the position of the needle tip in the GH joint is evaluated arthroscopically. An injection is considered successful if saline solution can be injected and the needle tip can be visualized intra-articularly. RESULTS: This study enrolled 195 patients undergoing shoulder arthroscopy. Successful needle placement in the GH joint occurred in 179 patients (91.8%); placement occurred through the rotator interval in 122 of these, adjacent or through the long head of the biceps tendon in 41, through the upper subscapularis or anterior supraspinatus in 13, and through the anterior labrum in 3. Regarding the 16 failures (8.2%), the needle position did not allow saline solution to be injected because of high resistance in 3 patients whereas the needle tip was not visualized in 13. The needle tip was presumed to rest within the subscapularis muscle or tendon or the labrum in 10 failed injections. CONCLUSIONS: The trans-coracoacromial ligament injection technique showed a high success rate (91.8%) in anesthetized patients about to undergo arthroscopy, whereas the failed injections mainly occurred because the needle was inserted into the subscapularis or labrum. This technique can be used for awake patients with different diagnoses in multiple settings. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Coracoid morphology is not associated with subscapularis tears.

BACKGROUND: The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears. METHODS: In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients' subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests. RESULTS: The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13). CONCLUSIONS: We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

Nonoperative Management of Hip Labral Tears Yields Similar Total Hip Arthroplasty Conversion Rate to Arthroscopic Treatment.

BACKGROUND: Arthroscopic treatment of hip labral tears has increased significantly in recent years. There is limited evidence comparing nonoperative management to arthroscopic treatment. The purpose of this study is to evaluate the progression to total hip arthroplasty (THA), as well as the cost associated with arthroscopic management of labral tears compared to nonoperative treatment. METHODS: The Humana claims database was queried from 2007 through 2016. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients with hip labral tears and hip arthroscopy and THA procedures. Two cohorts were created: a nonoperative group and an operative group. Following propensity score matching, the rate of conversion and time to THA conversion were calculated. Cost was calculated using the total cost reimbursed for encounters within 6 months. Continuous variables were analyzed using Student t-test and Mann-Whitney test, and categorical variables were analyzed using chi-square test. RESULTS: After propensity matching, 864 patients were included in the analysis. The conversion rate to THA in the operative group (6.7%) and the nonoperative group (5.3%) was not statistically different (P = .391). The operative group had a longer time to THA (21.5 ± 16.8 months) than the nonoperative group (15.9 ± 19.5 months; P = .044). The cost for the operative group was significantly higher ($14,266.55 ± $7187.96) compared to the nonoperative group ($2941.96 ± $2664.00; P < .001). CONCLUSION: This study did not find a difference in the rate of conversion to THA for operative vs nonoperative groups. Time to THA in the operative group was longer, however, at the expense of higher costs.