Open and Arthroscopic Elbow Contracture Release: Tips and Pearls.

Elbow stiffness is a common consequence of trauma and can significantly limit the functionality of the affected arm. Intervention may be necessary for those with a motion arc less than 100°, but the decision to intervene should be based on individual patient needs. Restoration of joint motion in a stiff elbow can be challenging, time consuming, and costly. Nonsurgical treatment is the primary management option, and surgical intervention is considered for refractory stiffness. However, recurrent stiffness is a common issue following surgical elbow contracture release. An overview of relevant elbow anatomy, principles and technical pearls of arthroscopic and open contracture release, and postoperative rehabilitation methods to reduce the risk of recurrent stiffness is provided. It is important to tailor the treatment plan to each patient's unique needs and functional expectations.

Internal rotation limitation is prevalent following modern reverse shoulder arthroplasty and negatively affects patients' subjective rating of the procedure.

BACKGROUND: Although forward elevation, abduction, and external rotation are often successfully restored, internal rotation (IR) is frequently not satisfactorily recovered following reverse shoulder arthroplasty (RSA), affecting patients' ability to perform certain daily activities. This study examined the prevalence of limited IR in patients receiving modern RSA and its impact on clinical outcomes and patient satisfaction with their RSA. METHODS: A cross-sectional study was conducted on patients who had undergone primary RSA using a modern RSA prosthesis with a minimum 1-year follow-up. Patients returned for a research visit where they were examined for range of motion and surveyed for patient-reported outcome measures (PROMs) and subjective rating of the success level of their RSA. Postoperative range of motion data were compared with the preoperative data. The relationship of postoperative IR with PROMs and patients' subjective rating of RSA was analyzed. Logistic regression was performed to identify factors affecting patients' subjective rating of RSA. RESULTS: A total of 78 patients met the criteria and completed the study. A significant portion (59%) reported subjective IR limitations, and 41% had objective IR limitations. Comparison of preoperative and postoperative IR showed that 24% had worsened IR, whereas 33% improved. Limited IR was associated with lower patients' subjective rating of RSA and negatively affected PROMs, especially when the dominant side was operated on. Regression analysis showed that limited IR was the only independent determining factor that was significantly associated with a lower subjective rating of RSA. DISCUSSION: Despite advancements in RSA design, limited IR remains a prevalent issue, significantly affecting patients' satisfaction and clinical outcomes. This study underscores the need for setting appropriate expectations regarding IR through patient education and focused efforts to improve IR limitations in RSA patients, particularly on the dominant side.

Effect of making skin incision with electrocautery on positive Cutibacterium acnes culture rates in shoulder arthroplasty: a prospective randomized clinical trial.

BACKGROUND: Cutibacterium acnes remains the most commonly detected organism in shoulder arthroplasty. C acnes infection is thought to occur during shoulder arthroplasty through contamination of the surgical field with C acnes from the incised dermis. The purpose of this study was to examine whether using electrocautery for making skin incisions would decrease C acnes culture rates at the incised dermis compared to using scalpels during shoulder arthroplasty. METHODS: Patients undergoing primary shoulder arthroplasty were randomized into 2 groups, electrocautery vs. scalpel incision group. All patients received a standard preoperative antiseptic preparation including chlorhexidine gluconate showers, intravenous antibiotic administration, and topical application of hydrogen peroxide, povidone iodine, isopropyl alcohol, and DuraPrep. Cultures were obtained from the incised dermal edge immediately after skin incision and later from surgeon's gloves and forceps immediately prior to humeral component implantation. The primary outcome was positive C acnes culture rates compared between the groups. RESULTS: A total of 64 patients (32 in each group) were enrolled. There were 24 males in each group. Regarding dermis cultures, 10 patients (31%) in the scalpel group were positive with 8 of them positive for C acnes, whereas no patients in the electrocautery group were positive (P < .001). Regarding glove cultures, the electrocautery group had 8 patients positive C acnes, while the scalpel group had 8 (P = .777). Regarding forceps cultures, the electrocautery group had 4 patients positive for C acnes, and the scalpel group had 6 (P = .491). All positive cultures were exclusively from male patients. There were no wound complications or infection in the electrocautery group while the scalpel group had 1 acute postoperative infection. CONCLUSIONS: Making skin incisions using electrocautery resulted in 0 C acnes culture at the incised dermis, suggesting its potential effect against C acnes. However, despite this initial antibacterial effect, C acnes still appeared on surgeon's gloves and forceps during surgery of male patients. All positive cultures were from male patients, suggesting that the source of C acnes was specifically related to the male body. While the study hypothesis was supported by the results, the present study also raises new questions and calls for further research.

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.

Interdepartmental imaging protocol for clinically based three-dimensional computed tomography can provide accurate measurement of glenoid version.

BACKGROUND: Conventional computed tomography (CT) is not accurate for glenoid version measurement. This study sought to examine the feasibility of an interdepartmental protocol implemented between orthopedic surgery and radiology departments for acquisition of anatomic axial CT images and to validate the glenoid version measured through such a protocol. MATERIALS AND METHODS: Data of 30 conventional CT scans of 10 normal and 20 osteoarthritic glenoids were transferred to clinical 3-dimensional imaging software by a radiology technician trained for the study. The technician independently reoriented the scapulae to generate anatomic CT images. A separate team of orthopedic researchers used laboratory-based 3-dimensional reconstruction software (Mimics; Materialise, Leuven, Belgium) to generate anatomic axial images. Three independent examiners measured glenoid version on the conventional CT, reoriented anatomic CT, and Mimics images at the superior, middle, and inferior levels. Data were analyzed using the Mimics data as the "gold standard." RESULTS: Reoriented anatomic CT images generated by the technician resulted in almost identical version measurements to the Mimics images in both normal and arthritic glenoids. The conventional CT images had poor agreement with the Mimics images in normal glenoids but had good agreement in arthritic glenoids. Both normal and arthritic glenoids had increased retroversion superiorly (P < .05), and this phenomenon was significantly exaggerated on the conventional CT images (P < .05). CONCLUSIONS: This study demonstrated that an interdepartmental protocol can produce reoriented anatomic axial CT images on which true glenoid version can be accurately measured. Such an institutional protocol would help surgeons accurately evaluate glenoid version preoperatively with reduced workload and expense.

Role of transplanted bone marrow cells in development of rotator cuff muscle fatty degeneration in mice.

BACKGROUND: Rotator cuff muscle fatty degeneration after a chronic tendon tear is an irreversible pathologic change associated with poor clinical outcomes of tendon repair, and its exact pathogenesis remains unknown. We sought to investigate the role of transplanted bone marrow cells in the development of fatty degeneration, specifically in adipocyte accumulation, using a mouse model. METHODS: Fourteen mice were divided into 2 bone marrow chimeric animal groups: bone marrow transplantation (BMT) group and reverse BMT group. For the BMT group, C57BL/6J wild-type mice underwent whole body irradiation followed by BMT into the retro-orbital sinus from green fluorescent protein (GFP)-transgenic donor mice. For the reverse BMT group, GFP-transgenic mice received BMT from C57BL/6J wild-type donor mice after irradiation. The supraspinatus tendon, infraspinatus tendon, and suprascapular nerve were surgically transected 3 weeks after transplantation. The rotator cuff muscles were harvested 13 weeks after transplantation for histologic analysis and GFP immunohistochemistry. RESULTS: On histologic examination, both groups showed substantial fatty degeneration, fibrosis, and atrophy of the cuff muscles. The BMT group showed no noticeable GFP immunostaining, whereas the reverse BMT group showed significantly stronger GFP staining in most adipocytes (P < .001). However, both groups also showed that a small number of adipocytes originated from transplanted bone marrow cells. A small number of myocytes showed a large cytoplasmic lipid vacuole resembling adipocytes. CONCLUSIONS: This study's findings suggest that most adipocytes in fatty degeneration of the rotator cuff muscles originate from sources other than bone marrow-derived stem cells, and there may be more than 1 source for the adipocytes.

Effect of ulnar tunnel location on elbow stability in double-strand lateral collateral ligament reconstruction.

BACKGROUND: Double-strand lateral ulnar collateral ligament (LUCL) reconstruction is an effective treatment for posterolateral rotatory instability (PLRI) of the elbow, but anatomic landmarks for ulnar tunnel placement are often difficult to identify intraoperatively, which potentially can result in a nonanatomic LUCL reconstruction. This study investigated the effect of ulnar tunnel location on joint stability in double-strand LUCL reconstruction. METHODS: PLRI was artificially created in 7 cadaveric elbows, and double-strand LUCL reconstruction was performed. Five different ulnar tunnels were made along the length of the ulna. In each specimen, each possible pair of 2 tunnels (10 total) were used for graft passage. Varus and posterolateral joint gapping was measured after joint loading using a 3-dimensional digitizer system and X-ray image intensifier. RESULTS: No significant gapping was observed at the posterolateral ulnohumeral joint regardless of the location of the ulnar tunnels (P > .05). In contrast, the lateral radiocapitellar joint showed statistically significant varus gapping when both ulnar tunnels were placed proximal to the radial head-neck junction (P < .05). DISCUSSION: This findings of study suggest that the location of the ulnar tunnels may not be as critical as that of the humeral tunnel during double-strand LUCL reconstruction and that posterolateral rotatory elbow stability can be achieved reasonably well as long as at least 1 of the 2 ulnar tunnels is located at or distal to the radial head-neck junction level.

Intraoperative fluoroscopic assessment of proper prosthetic radial head height.

BACKGROUND: Selecting a properly sized radial head prosthesis is imperative during radial head replacement. Although there has been much emphasis on avoiding overlengthening of the radius, little has been studied about how to avoid shortening. The purpose of this study was to characterize how a radial head replacement appears on intraoperative fluoroscopy depending on the height of the prosthetic radial head. METHODS: Articular cartilage thickness of the radial head was measured in 9 cadaveric elbows. Radial head replacement was performed in each specimen with 4 different prosthetic head heights: 4 mm and 2 mm shortening, anatomic, and 2 mm overlengthening. Anteroposterior fluoroscopic images were obtained for each head height, and the prosthetic radial head height was measured at 3 forearm positions (supination, neutral, and pronation) using the subchondral bone of the lateral edge of the coronoid at the reference point. RESULTS: The mean cartilage thickness of the radial head was 1.3 ± 0.4 mm. The prosthetic radial head appeared 2.2 ± 0.4 mm more proximal than the subchondral bone of the coronoid lateral edge in anteroposterior radiographs when the articular surface of the prosthesis was completely even with the coronoid articular surface. Unlike the native radial head, a prosthetic radial head showed a significant change of height with different forearm rotation (P < .001). DISCUSSION: This study found that a perfectly anatomic radial head replacement appears overlengthened by approximately 2 mm in intraoperative radiographs. This finding can be useful in guiding the appropriate height of a prosthetic radial head.

Posterior Displacement of Supraspinatus Central Tendon Observed on Magnetic Resonance Imaging: A Useful Preoperative Indicator of Rotator Cuff Tear Characteristics.

PURPOSE: To characterize the orientation of the normal supraspinatus central tendon and describe the displacement patterns of the central tendon in rotator cuff tears using a magnetic resonance imaging (MRI)-based method. METHODS: We performed a retrospective MRI and chart review of 183 patients with a rotator cuff tear (cuff tear group), 52 with a labral tear but no rotator cuff tear (labral tear group), and 74 with a normal shoulder (normal group). The orientation of the supraspinatus central tendon relative to the bicipital groove was evaluated based on axial MRI and was numerically represented by the shortest distance from the lateral extension line of the central tendon to the bicipital groove. Tear size, fatty degeneration, and involvement of the anterior supraspinatus were evaluated to identify the factors associated with orientation changes. RESULTS: The mean distance from the bicipital groove to the central tendon line was 0.7 mm and 1.3 mm in the normal group and labral tear group, respectively. Full-thickness cuff tears involving the anterior supraspinatus showed a significantly greater distance (17.7 mm) than those sparing the anterior supraspinatus (4.9 mm, P = .001). Fatty degeneration of the supraspinatus was significantly correlated with the distance (P = .006). Disruption of the anterior supraspinatus and fatty degeneration of the supraspinatus were independent predictors of posterior displacement. CONCLUSIONS: The supraspinatus central tendon has a constant orientation toward the bicipital groove in normal shoulders, and the central tendon is frequently displaced posteriorly in full-thickness rotator cuff tears involving the anterior leading edge of the supraspinatus. The degree of posterior displacement is proportional to tear size and severity of fatty degeneration of the supraspinatus muscle. A simple and quick assessment of the central tendon orientation on preoperative MRI can be a useful indicator of tear characteristics, potentially providing insight into the intraoperative repair strategy. LEVEL OF EVIDENCE: Level IV, diagnostic case-control study.

Functional outcomes after shoulder resection: the patient's perspective.

BACKGROUND: Resection arthroplasty is a salvage procedure used for the treatment of deep-seated infections after total shoulder arthroplasty, hemiarthroplasty, and reverse total shoulder arthroplasty. Previous studies have reported a 50% to 66% rate of pain relief after resection arthroplasty but with significant functional limitations. Our study aimed to qualify the perspective of the patients on their limitations and satisfaction with resection arthroplasty. METHODS: A retrospective record review of resection arthroplasties performed between September 2003 and December 2012 yielded 14 patients, and 7 completed the survey. The patients completed surveys with the focus on the "patient perspective." Functional scores, including American Shoulder and Elbow Surgeons, Simple Shoulder Test, Disabilities of the Arm, Shoulder, and Hand (DASH), DASH work, and DASH sports, were determined. RESULTS: Pain reduction and functional outcomes were similar to past reports of resection arthroplasty. Five of the 7 patients (71%) reported satisfaction with their resection arthroplasty, and 6 of the 7 patients (86%) would undergo the procedure again if given the choice. Five of the 7 patients (71%) were able to most of activities of daily living. CONCLUSIONS: Patients in our study were generally satisfied with their resection arthroplasty. Resection arthroplasty is a reasonable option for treatment of deep-seated periprosthetic infections or for patients with multiple previous failed procedures for total shoulder arthroplasty, hemiarthroplasty. and reverse shoulder arthroplasty.

Teres minor muscle and related anatomy.

BACKGROUND: The purpose of this study was to describe the complex anatomy surrounding the teres minor muscle. METHODS: Thirty-one cadaveric human shoulders were dissected. Qualitative fascial and neurovascular anatomy were described. Location of motor nerves to teres minor were measured in reference to local anatomy. RESULTS: Fascial anatomy of the posterior shoulder had 2 distinct and equally common variants, 1 of which demonstrated a stout, inflexible fascial compartment enveloping the teres minor muscle. The other had a continuous fascia enveloping both the infraspinatus and teres minor muscles. In both variants, the primary nerve to teres minor traveled around a fascial sling, becoming sub-fascial at an average of 44 mm (range, 25-68) medial to the teres minor's insertion. The nerve took its most angulated course as it entered the fascial sling. Smaller accessory innervation of teres minor began, on average, 30 mm (range, 15-48) medial to the muscle's lateral insertion. None of the accessory motor nerves coursed deep to the fascial sling nor to the distinct teres minor fascial compartment. CONCLUSION: A stout fascial sling may be the potential site of greatest compression and tethering of the primary motor nerve to teres minor. Additional lateral accessory motor nerves to teres minor remained extra-fascial and took a less angulated path. Half of the shoulders demonstrated a separate teres minor fascial compartment. An improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians who treat patients with symptomatic isolated teres minor muscle atrophy.

Glenoid articular conformity affects stress distributions in total shoulder arthroplasty.

BACKGROUND: The stress applied to the glenoid component in total shoulder arthroplasty (TSA) remains an important concern because of the risk of wear and loosening. The purpose of this study was to determine the stress pattern in the glenoid component with 3 different surface designs. METHODS: Computer models of 9 scapulae of patients scheduled for TSA were created from computerized tomography images. Each glenoid was virtually reamed, and 3 different glenoid component designs (conforming, nonconforming, and hybrid) were placed. Using finite element analysis, superior translation of the humeral head was modeled. Maximum stress and shear stress were measured at 3 different locations in the glenoid component: center, transition, and superior regions. RESULTS: All 3 designs showed a similar level of maximum stress at the center and transition regions, while the maximum stress at the superior periphery was significantly higher in the conforming design than in the other 2 designs (P = .0017). The conforming design showed significantly higher shear stress at the superior periphery (P < .0001). DISCUSSION: Stress from periphery loading is higher than from the center and transition region regardless of component design and is highest in the conforming design. The stress at the transition region of the hybrid design was not higher than the other 2 designs. The hybrid design has favorable characteristics based on its low stress at the periphery and greater contact area with the humeral head at the center. LEVEL OF EVIDENCE: Basic Science Study, Biomechanical Computer Simulation Study.

Glenoid implant orientation and cement failure in total shoulder arthroplasty: a finite element analysis.

BACKGROUND: To minimize glenoid implant loosening in total shoulder arthroplasty (TSA), the ideal surgical procedure achieves correction to neutral version, complete implant-bone contact, and bone stock preservation. These goals, however, are not always achievable, and guidelines to prioritize their impact are not well established. The purpose of this study was to investigate how the degree of glenoid correction affects potential cement failure. METHODS: Eight patient-specific computer models were created for 4 TSA scenarios with different permutations of retroversion correction and implant-bone contact. Two bone models were used: a homogeneous cortical bone model and a heterogeneous cortical-trabecular bone model. A 750-N load was simulated, and cement stress was calculated. The risk of cement mantle fracture was reported as the percentage of cement stress exceeding the material endurance limit. RESULTS: Orienting the glenoid implant in retroversion resulted in the highest risk of cement fracture in a homogeneous bone model (P < .05). In the heterogeneous bone model, complete correction resulted in the highest risk of failure (P = .0028). A positive correlation (ρ = 0.901) was found between the risk of cement failure and amount of exposed trabecular bone. CONCLUSIONS: Incorporating trabecular bone into the model changed the effect of implant orientation on cement failure. As exposed trabecular bone increased, the risk of cement fracture increased. This may be due to shifting the load-bearing support underneath the cement from cortical bone to trabecular bone.

Arthroscopic Bone Block Cerclage Suture Fixation of Fresh Distal Tibial Allograft for Anterior Glenoid Reconstruction.

Glenoid bone loss in patients with recurrent anterior shoulder instability poses a unique challenge to treating surgeons. Various bone block procedures have been used to reconstruct the glenoid, including autologous coracoid transfer, iliac crest autograft, distal clavicle autograft, and distal tibia allograft. Distal tibia allograft has been increasingly used because of its advantages over autologous graft sources. Having started out as an open procedure, glenoid reconstruction with distal tibia allograft has now found its way to evolving into an arthroscopic procedure. Various techniques have been devised for arthroscopic distal tibia allograft fixation, including screw, suture anchor, and suture button. This technical note describes an arthroscopic distal tibia allograft fixation technique, using a transglenoid parallel drill guide and 2 cerclage tape sutures that are fastened using a tensioner. This technique provides strong graft fixation while avoiding the potential complications and technical challenges of metal screw fixation.

The effect of tear size and nerve injury on rotator cuff muscle fatty degeneration in a rodent animal model.

BACKGROUND: Irreversible muscle changes after rotator cuff tears is a well-known negative prognostic factor after shoulder surgery. Currently, little is known about the pathomechanism of fatty degeneration of the rotator cuff muscles after chronic cuff tears. The purposes of this study were to (1) develop a rodent animal model of chronic rotator cuff tears that can reproduce fatty degeneration of the cuff muscles seen clinically, (2) describe the effects of tear size and concomitant nerve injury on muscle degeneration, and (3) evaluate the changes in gene expression of relevant myogenic and adipogenic factors after rotator cuff tears using the animal model. MATERIALS AND METHODS: Rotator cuff tears were created in rodents with and without transection of the suprascapular nerve. The supraspinatus and infraspinatus muscles were examined at 2, 8, and 16 weeks after injury for histologic evidence of fatty degeneration and expression of myogenic and adipogenic genes. RESULTS: Histologic analysis revealed adipocytes, intramuscular fat globules, and intramyocellular fat droplets in the tenotomized and neurotomized supraspinatus and infraspinatus muscles. Changes increased with time and were most severe in the muscles with combined tenotomy and neurotomy. Adipogenic and myogenic transcription factors and markers were upregulated in muscles treated with tenotomy or tenotomy combined with neurotomy compared with normal muscles. CONCLUSIONS: The rodent animal model described in this study produces fatty degeneration of the rotator cuff muscles similar to human muscles after chronic cuff tears. The severity of changes was associated with tear size and concomitant nerve injury.

A physician's guide to the physical examination of the shoulder.

Shoulder pain is the third most frequent musculoskeletal complaint presented to physicians. Often considered a benign entity by patients and even their physicians, shoulder disorders can have a devastating effect on a patient's ability to function, as well as serve as an indicator of poor general health. For these reasons, it is important for the physician to be able to identify the etiology of a patient's shoulder problem(s). However, making a correct diagnosis is often difficult because there can be many causes for a patient's shoulder pain, weakness, or loss of function. Moreover, the shoulder girdle is an intricate group of structures that work together to allow for the largest range of motion in the body. This complexity makes it difficult to diagnose a patient's condition(s) based on history alone. A thorough and well-performed physical examination is the key to making a correct diagnosis and helping to distinguish different etiologies of shoulder dysfunction. In this article, we review relevant shoulder anatomy and biomechanics, and general shoulder examinations with special tests for various shoulder pathologies. We provide an effective and methodical approach to the physical examination of the shoulder.

Clinical Fate of Glenohumeral Osteoarthritis Following Intraarticular Corticosteroid Injection: An Analysis in 311 Shoulders.

Background: Intraarticular corticosteroid injection is commonly used conservative treatment for glenohumeral osteoarthritis (OA). The purpose of this study was to investigate the clinical fate of symptomatic glenohumeral OA following intraarticular corticosteroid injection and to identify factors associated with undergoing shoulder arthroplasty. Methods: Glenohumeral OA patients who had undergone at least one glenohumeral corticosteroid injection from 2012 to 2017 were identified. Data for demographics, comorbidities, number of injections, severity of radiographic arthritis, and subsequent treatment were collected up to February 2020. Data were analyzed to compare between patients who had eventually undergone shoulder arthroplasty and those who had not. Results: A total of 311 shoulders (275 patients) were followed up for 3 to 8 years after the index injection. The mean age of patients was 64.7 years. There were 148 females, and 116 shoulders (37.3%) eventually underwent arthroplasty, 68 (21.9%) further injections only, 104 (33.4%) no further treatment, 14 (4.5%) a non-arthroplasty surgical procedure, and 9 (2.9%) were lost to follow up. Severity of radiographic arthritic changes, female sex, younger age, and nonsmoking status were found to be significantly associated with undergoing arthroplasty (p < 0.001, p = 0.014, p = 0.003, and p = 0.043, respectively). Conclusion: Approximately one third of glenohumeral OA patients who had received an intraarticular corticosteroid injection eventually elected to undergo shoulder arthroplasty within 3 to 8 years of the injection. High-grade arthritic changes in radiographs, female gender, and younger age were found to be independent factors associated with undergoing arthroplasty. This information may be useful in counseling patients about their future clinical course.Level of Evidence: Level III Retrospective comparative study.

Utility of lateral scapular radiographs in initial evaluation of nontraumatic shoulder conditions.

Background: Lateral scapular radiographs have been routinely included in the initial radiographic examination of both traumatic and nontraumatic shoulder conditions. With the advance of modern imaging modalities, the clinical utility of the lateral scapular view has become questionable. The purpose of the study was to assess the utilization of the lateral scapular view among the members of the American Shoulder and Elbow Surgeons (ASES) and to determine the clinical utility of the lateral scapular view in the initial evaluation of nontraumatic shoulder conditions. Methods: The study consisted of two parts. The first part involved an online survey of ASES members, which asked them 3 questions regarding their preference for radiographic evaluation of new patients with nontraumatic shoulder pain. The second part involved a clinical vignette-based survey, where 4 shoulder surgeons at our institution were given 50 clinical vignettes and asked to independently answer 4 questions regarding the most probable diagnosis, abnormal radiographic findings, further imaging studies, and treatment plan for each case. The survey was repeated twice; the first was given without a lateral scapular view, and the second given 4 weeks later with a lateral scapular view included. We obtained diagnostic accuracy and percent agreement of each surgeon over two surveys and intraobserver and interobserver reliability on each variable. Results: Of a total of 235 ASES members who responded to the online survey, 193 (82.1%) indicated their routine use of a lateral scapular view. The most common reason for obtaining the view was better characterization of acromion morphology (75.4%). The clinical vignette-based survey showed substantial intrarater reliability (κ > 0.6) of the 4 surgeons between the two surveys for the most probable diagnosis, abnormal x-ray findings, and further imaging studies, while the intrarater reliability for treatment plan was moderate (κ = 0.548). The mean diagnostic accuracy of the 4 surgeons was almost equal (74% vs. 75%) between the surveys. Overall, each surgeon's percent agreement across the 2 surveys was over 70%. None of the 4 surgeons recommended a lateral scapular view for further imaging during the first survey; each wanted either advanced imaging (computed tomography, magnetic resonance imaging) or none. Discussion: The addition of a lateral scapular radiograph in the presence of other orthogonal views does not appear to improve surgeons' diagnostic accuracy or affect their decision-making on the treatment plan in nontraumatic shoulder conditions. The clinical utility of the lateral scapular view may need to be reassessed in this setting.

Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial.

BACKGROUND: While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty. METHODS: Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block. RESULTS: The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA. CONCLUSIONS: LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

The role of transforming growth factor beta isoforms in tendon-to-bone healing.

The purpose of this study was to examine the role of two of the three transforming growth factor beta (TGF-ß) isoforms at the healing tendon-to-bone insertion. The supraspinatus tendons of 64 rats were transected at their bony insertions and repaired to the humeral head. One shoulder of each rat received an osmotic pump for sustained delivery of the following factors at the repair site: (1) TGF-ß1 and neutralizing antibodies to TGF-ß2 and 3 (TGF-ß1 group), (2) TGF-ß3 and neutralizing antibodies to TGF-ß1 and 2 (TGF-ß3 group), (3) neutralizing antibodies to TGF-ß1, 2, and 3 (anti-TGF-ß group), and (4) saline (saline group). The contralateral shoulders received saline to serve as paired controls. The repairs were evaluated at multiple time points postmortem using histology-based assays and biomechanical testing. Treated shoulders in the TGF-ß1 group showed increased type III collagen production compared to the paired control shoulders, indicative of a scar-mediated response. There was a trend toward reduced mechanical properties in the TGF-ß1 group, but these changes did not reach statistical significance. The anti-TGF-ß group showed no difference in tissue volume, but significantly inferior mechanical properties, compared to the paired control shoulders. The TGF-ß3 group did not show any differences compared to the paired control shoulders. Although TGF-ß isoforms play important roles in tendon-to-bone development and healing, application of exogenous TGF-ß isoforms and neutralizing antibodies to the subacromial space using osmotic pumps did not improve supraspinatus tendon-to-bone healing.