Variable Return to Play and Sport Performance After Elbow Ulnar Collateral Ligament Reconstruction in Baseball Players: A Systematic Review.

PURPOSE: To evaluate return to play (RTP) and return to same level of play (RTSP) rates as well as preoperative and postoperative in-game performance metrics in baseball pitchers who underwent ulnar collateral ligament reconstruction (UCLR). Secondarily, this review sought to assess outcomes based on primary versus revision UCLR as well as level of competition. METHODS: This review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane Database of Systematic Reviews were queried to identify articles evaluating UCLR in baseball players between January 2002 and October 2022. Data included RTP, RTSP, and performance metrics including earned run average, innings pitched, walks and hits per inning pitched, batting average against, strikeouts per 9 innings, walks per 9 innings, percentage of fastballs thrown, and average fastball velocity. The Methodological Index for Non-randomized Studies criteria were used for quality assessment. RESULTS: Analysis included 25 articles reporting on 2,100 elbows. After primary UCLR, RTP ranged from 336 to 615 days (57% to 100% achieved) and RTSP ranged from 330 to 513 days (61% to 95%). After revision UCLR, RTP ranged from 381 to 631 days (67% to 98%) and RTSP ranged from 518 to 575 days (42% to 78%). When stratifying primary UCLR outcomes by competitive level, RTP and RTSP ranged respectively from 417 to 615 days (75% to 100%) and 513 days (73% to 87%) for Major League Baseball only, 409 to 615 days (57% to 100%) and 470 to 513 days (61% to 95%) for Major League Baseball plus Minor League Baseball, and 336 to 516 days (73% to 85%) and 330 days (55% to 74%) for college plus high school. Heterogeneity was seen in postoperative sports performance metrics. CONCLUSIONS: Although more than half of baseball players appear able to RTP after primary and revision UCLR, RTSP rates after revision UCLR were as low as 42% in the literature. Preoperative and postoperative performance metrics varied. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis.

BACKGROUND: Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS: Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS: Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

Reported Outcome Measures in Complex Fracture Elbow Dislocations: A Systematic Review.

BACKGROUND: Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison. METHODS: A systematic review was performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for non-randomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded. RESULTS: Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n=70), extension (n=62), pronation (n=68), or supination (n=67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (MEPS) (n=69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n=28 [34%]), the visual analog scale for pain (VAS) (n=27 [33%]), QuickDASH score (n=13 [15.7%]), and Oxford Elbow score (n=5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P=.313), study type (P=.689), complex fracture pattern (P=.211), or number of elbows included (P=.152). CONCLUSION: There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the MEPS and DASH outcomes measures as well as VAS pain rating scale in future studies to facilitate cross-study comparisons.

Establishing the diagnosis of radial tunnel syndrome: a systematic review of published clinical series.

PURPOSE: Radial tunnel syndrome (RTS) is a controversial diagnosis due to non-specific exam findings and frequent absence of positive electromyography (EMG) and nerve conduction study (NCS) findings. The purpose of this study was to identify the methods used to diagnose RTS in the literature. METHODS: We queried PubMed, Embase, Web of Science, and Cochrane databases per PRISMA guidelines. Extracted data included article and patient characteristics, diagnostic assessments utilized and their respective findings, and treatments. Objective data were summarized descriptively. The relationship between reported diagnostic findings (i.e., physical exam and diagnostic tests) and treatments was assessed via a descriptive synthesis. RESULTS: Our review included 13 studies and 391 upper extremities. All studies utilized physical exam in diagnosing RTS; most commonly, patients had tenderness over the radial tunnel (381/391, 97%). Preoperative EMG/NCS was reported by 11/13 studies, with abnormal findings in 8.9% (29/327) of upper extremities. Steroid and/or lidocaine injection for presumed lateral epicondylitis was reported by 9/13 studies (46/295 upper extremities, 16%), with RTS being diagnosed after patients received little to no relief. It was also common to inject the radial tunnel to make the diagnosis (218/295, 74%). The most common reported intraoperative finding was narrowing of the PIN (38/137, 28%). The intraoperative compressive site most commonly reported was the arcade of Frohse (142/306, 46%). CONCLUSIONS: There is substantial heterogeneity in modalities used to diagnose RTS and the reported definition of RTS. This, in conjunction with many patients having concomitant lateral epicondylitis, makes it difficult to compare treatment outcomes for RTS. LEVEL OF EVIDENCE: Level III. Systematic review of retrospective and prospective cohort studies.

The medial forearm fascia and lateral forearm fascia contribute to overhead elbow extension in displaced olecranon fractures: a biomechanical study.

BACKGROUND: In nonoperative management of displaced olecranon fractures, patients are able to maintain overhead extension despite a persistent nonunion. It has been hypothesized that this is feasible because of an intact lateral cubital retinaculum. The purpose of this biomechanical study was to determine the contribution of the medial and lateral cubital retinacula to overhead extension in the setting of a displaced olecranon fracture. METHODS: Eight fresh-frozen cadaveric upper-extremity specimens were used in this study. The triceps muscle was loaded through a pulley system operated by an Instron 8874 Biaxial Servohydraulic Fatigue Testing System at a rate of 10 mm/second to simulate overhead elbow extension. Each specimen was tested in 4 states: (1) native state with an intact olecranon; (2) transverse olecranon fracture; (3) transection of 1 cubital retinaculum (medial or lateral); and (4) transection of both medial and lateral cubital retinacula. The primary outcome was the ability to perform overhead extension. The secondary outcome was the force needed to generate extension. RESULTS: Elbow extension was noted in each specimen for trials 1, 2, and 3. Only when both the lateral fascia and medial fascia were transected was elbow extension not achieved. There was no significant difference in the force required to generate extension in the first 3 trials (P = .99). There was no significant difference in the change in the maximum force required to achieve extension between the specimens with only the medial side transected and the specimens with only the lateral side transected (P = .07). DISCUSSION: In the setting of an olecranon fracture, this biomechanical study suggests that if either the lateral or medial cubital retinaculum remains in continuity with the distal ulna, active overhead extension can be maintained. This finding may explain the positive clinical outcomes of nonoperative management of displaced olecranon fractures in the elderly patient population. Determining the integrity of the fascial structures preoperatively may help select candidates for nonoperative treatment of displaced olecranon fractures.

Do outcomes of interposition arthroplasty in young patients differ based on indication? A systematic review.

BACKGROUND: Interposition arthroplasty of the elbow is often preferred in young patients compared with implant total elbow arthroplasty. However, research comparing outcomes based on diagnosis in patients with post-traumatic osteoarthritis (PTOA) and inflammatory arthritis following interposition arthroplasty is sparse. Therefore, the purpose of this study was to compare outcomes and complication rates following interposition arthroplasty in patients with PTOA and inflammatory arthritis. METHODS: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Web of Science databases were queried from inception to December 31, 2021. The search generated 189 total studies, of which 122 were unique. Original studies on interposition arthroplasty of the elbow in the setting of post-traumatic or inflammatory arthritis in patients aged <65 years were included. Six studies that were suitable for inclusion were identified. RESULTS: The query yielded 110 elbows, of which 85 had received a diagnosis of PTOA and 25, inflammatory arthritis. The cumulative complication rate following the index procedure was 38.4%. The complication rate in patients with PTOA was 41.2% compared with 11.7% in those with inflammatory arthritis. Furthermore, the cumulative reoperation rate was 23.5%. The reoperation rates in PTOA and inflammatory arthritis patients were 25.0% and 17.6%, respectively. The average preoperative Mayo Elbow Performance Index pain score was 11.0, which improved to 26.3 postoperatively. The mean preoperative and postoperative pain scores for the PTOA patients were 4.3 and 30.0, respectively. For the inflammatory arthritis patients, the preoperative pain score was 0 and the postoperative pain score was 45. The overall mean preoperative Mayo Elbow Performance Index functional score was 41.5, improving to 74.0 after the procedure. CONCLUSIONS: This study found that interposition arthroplasty is associated with a 38.4% complication rate and 23.5% reoperation rate, in addition to positive improvements in pain and function. In patients aged <65 years, interposition arthroplasty may be considered in those unwilling to undergo implant arthroplasty.

Surgeon confidence in planning total shoulder arthroplasty improves after consulting a clinical decision support tool.

PURPOSE: Software algorithms are increasingly available as clinical decision support tools (CDSTs) to support shared decision-making. We sought to understand if patient-specific predictions from a CDST would impact orthopedic surgeons' preoperative planning decisions and corresponding confidence. METHODS: We performed a survey study of orthopedic surgeons with at minimum of 2 years of independent shoulder arthroplasty experience. We generated patient profiles for 18 faux cases presenting with glenohumeral osteoarthritis and emailed 93 surgeons requesting their recommendation for anatomic or reverse total shoulder arthroplasty for each case and their certainty in their recommendation on a 4-point Likert scale. The thirty respondents were later sent a second survey with the same cases that now included predicted patient-specific outcomes and complication rates generated by a CDST. RESULTS: Initial recommendations and changes in recommendation varied widely by surgeon and by case. After viewing the results of the CDST, surgeons switched from anatomic to reverse recommendations in 46 instances (12% of initial anatomic) and from reverse to anatomic in 22 instances (6% of initial reverse). Overall, surgeon change in confidence increased significantly across all responses (p = 0.0001), with certain cases and certain surgeons having significant changes. Change in confidence did not correlate with surgeon-specific factors, including years in practice. CONCLUSION: The addition of CDST reports to preoperative planning for anatomic and reverse total shoulder arthroplasty informed decision-making but did not direct recommendations uniformly. However, the CDST information provided did increase surgeon confidence regardless of implant selection and irrespective of surgeon experience.

A bibliometric analysis of the 50 most influential publications on distal biceps repair.

PURPOSE: The purpose of this bibliometric study was to identify and analyze the most cited publications on acute distal biceps repair. METHODS: Using the Clarivate Analytics Web of Science database, we searched for the top 50 most cited publications on acute distal biceps repair and analyzed them based on various metrics. RESULTS: The top 50 publications were cited a total of 3171 times and approximately 151 times per year. However, although the literature on the topic is quite extensive, most publications only contain low-level evidence. In fact, 74% of the 50 most cited publications on the topic contain either level IV or V evidence. CONCLUSION: This study, through bibliometric analysis, demonstrates that the most often cited studies about acute distal biceps tendon repair are low level of evidence designs. This common injury and study design are ripe for larger randomized or prospective cohort studies.

The top 50 most cited articles on olecranon fractures: a bibliometric analysis.

PURPOSE: Citation analysis has been used to determine the impact of an article in a medical specialty. The purpose of this study was to identify the 50 most cited articles on olecranon fracture outcomes, indications, techniques, procedural descriptions, and complications and analyse their characteristics. METHODS: The Web of Science database was used to search for publications related to olecranon fractures. The top 50 most cited articles that met the inclusion criteria were recorded and reviewed in terms of journal and year of publication, country of origin, type of study, and level of evidence. RESULTS: The top 50 articles were cited a total of 2165 times and the year of publication ranged from 1957 to 2014. Of the 50 articles identified, 43 were case series correlating with a Level IV evidence designation. The top 50 articles were published in 20 different medical journals and originated from 18 different countries. CONCLUSION: The majority of the articles analysed were uncontrolled case series that reported outcomes and complications surrounding the operative treatment of olecranon fractures. The top 50 most influential articles pertaining to olecranon fractures provides physicians and residency programs with a high-yield list of publications to reference on the topic.

The top 50 most cited articles in both-bone forearm open reduction internal fixation in the skeletally mature patient.

PURPOSE: Both-bone forearm fractures in the adult population frequently and usually necessitate an operative reduction. The purpose of this study was to identify the 50 most cited publications regarding both-bone ORIF and evaluates their level of evidence to help guide the best treatment and management practices, as well as gauge the current level of inquiry into this topic. METHODS: The Clarivate Analytics Web of Knowledge Database was queried. The top 50 most cited articles identified as relevant were analyzed. Aggregate citation counts, citation density, type of study, and level of evidence were documented for each of the 50 articles. Abstracts from the last decade of prominent orthopaedic meetings were analyzed to determine the current level of inquiry into this area. RESULTS: The initial search yielded 408 results. There were 27 articles published before 2000 and 23 after. The total summation of citations for the top 50 articles totaled 2062. Each study was classified according to its study design and level of evidence. The most common was case series (34). Level IV studies were most numerous (34). Since 2010, the subject of both-bone forearm fracture ORIF was presented 8 times at prominent orthopaedic conferences. CONCLUSION: Our work demonstrated 54% of top-50 studies are pre-2000 and the majority are Level IV evidence. Additionally, despite the established treatment, there is active inquiry into this topic. Higher quality research can be helpful to validify treatment and management options.

Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018.

BACKGROUND: Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded. RESULTS: An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed. CONCLUSION: This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years. LEVEL OF EVIDENCE: III.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger.

PURPOSE: Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger. METHODS: A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2 groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation. RESULTS: Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies. CONCLUSIONS: For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The 50 most cited papers in chronic scapholunate reconstruction: a bibliometric analysis.

PURPOSE: This study identifies the most impactful papers on scapholunate reconstruction and provides a quantitative assessment of the impact of these papers in order to inform future clinical practice, education, and research of this condition. METHODS: The Scopus database was used in May 2020 to identify the 50 most cited clinical articles pertaining solely to chronic scapholunate reconstruction. Citation number and density, publication variables, and Altmetric Attention Scores (AASs) were collected and analyzed. RESULTS: The top 50 articles on chronic scapholunate reconstruction produced 1,868 total citations, with an average of 37.36 ± 39.90 citations per article (range 7-196) and an average citation density of 2.44 ± 2.27. US-based publications (n = 20) and articles published in Journal of Hand Surgery (n = 24) were associated with significantly higher citation number and density (p < 0.01 - p = 0.018). In addition, sample size was positively correlated with citation density (rho = 0.312, p = 0.029). Fourteen articles were associated with an AAS (mean score = 4.07 ± 4.70). There was no significant association between AAS and citation number or density, but AAS did significantly predict citation density (coefficient = 0.378, 95% CI: [0.013-0.741], p = 0.043). CONCLUSION: Numerous factors, such as journal of publication, location, and sample size, were significantly associated with citation number and/or citation density. Interestingly, AAS was predictive of, but not directly correlated with citation density, suggesting that the impact of scapholunate literature may not be adequately captured with a citation analysis.

A New Surface Landmark for Thumb Digital Nerve Bifurcation: A Cadaveric Study.

PURPOSE: The radial and ulnar thumb digital nerves are critical for tactile sensation and dexterity in the hand. This cadaveric study sought to validate a surface landmark for the bifurcation of the thumb radial digital nerve (RDN) and ulnar digital nerve (UDN). METHODS: We used 24 fresh-frozen cadaveric specimens for dissections. With the thumb placed in the plane of the palm and fully radially abducted, the index finger metacarpophalangeal joint was flexed to 90°. Then, while keeping the distal interphalangeal joint straight, the proximal interphalangeal joint was flexed until the fingertip contacted the thenar eminence to identify the point of bifurcation. We made a U-shaped incision and identified the bifurcation of the thumb RDN and UDN. The point of bifurcation was measured from the ulnar- and proximal-most aspects of the incision. RESULTS: The bifurcation of the thumb RDN and UDN was consistently identified within the U in 22 of 24 specimens (92%). In 16 specimens, the index RDN was also identified either trifurcating with the thumb RDN and UDN or branching from a common digital nerve of index RDN and thumb UDN. Most bifurcation points were found directly along the ulnar and proximal edge of the incision. Two specimens contained a bifurcation point 2 mm ulnar to the ulnar limb of the U. CONCLUSIONS: The bifurcation U is a consistent landmark for the thumb RDN and UDN point of bifurcation. The variable branching patterns in this region confirms the importance of thorough clinical examination with penetrating injuries to the thenar eminence. CLINICAL RELEVANCE: This surface anatomic landmark for the thumb RDN and UDN bifurcation may aid in preventing iatrogenic injuries during elective procedures and identifying at-risk structures during penetrating injuries to the palm.

Sequential fluoroscopic rollover images reliably identify "in-out-in" posterosuperior screws during percutaneous fixation of femoral neck fractures.

INTRODUCTION: Percutaneous screws placed into the posterosuperior femoral neck are frequently extraosseous or "in-out-in" (IOI). These IOI screws are not readily identifiable on anteroposterior (AP) and lateral fluoroscopic images. The purpose of this study was to examine the ability of surgeons to identify IOI guide pins using sequential fluoroscopic rollover images. MATERIALS AND METHODS: A 3.2-mm guide pin was placed into the posterosuperior quadrant of eleven synthetic femur models. Five samples were "all-in" (AI), and six were IOI. Sequential fluoroscopic rollover images were obtained starting with an AP image, then images at 10-degree rollover intervals ending with a direct lateral image. Images were reviewed in a blinded fashion by five attending orthopedic trauma surgeons and 20 resident surgeons to determine whether guide pins were AI or IOI. Accuracy, interobserver reliability, sensitivity, and specificity were assessed. RESULTS: The overall accuracy of responses was 86% with no difference between attending trauma surgeons and residents (p = 0.5). The sensitivity and specificity for an IOI guide pin were 98.0% and 71.2%, respectively. Interobserver reliability among surgeons was good (κ = 0.703). CONCLUSION: The use of the sequential fluoroscopic rollover images after placement of the posterosuperior guide pin into the femoral neck was highly sensitive for detecting an IOI position. The 40-degree rollover image was the best view to evaluate the proximity of the guide pin to the posterior cortex.

High incidence of "in-out-in" posterosuperior screws after cannulated screw fixation of femoral neck fractures.

INTRODUCTION: Cadaveric models have demonstrated a high incidence of extraosseous "in-out-in" (IOI) posterosuperior screws after cannulated screw fixation of femoral neck fractures. The purpose of this study was to determine the incidence of IOI screws in vivo and to evaluate their association with osteonecrosis and revision surgery. METHODS: A total of 104 patients with 107 hips with a pelvis computed tomography (CT) scan after cannulated screw fixation of a femoral neck fractures were included. Screw position was evaluated on postoperative radiographs and CT scan to determine if screws were IOI or all-in. Osteonecrosis and revision surgeries were documented. RESULTS: IOI posterosuperior screws were identified on CT scan in 58 (54%) hips. On postoperative AP and lateral radiographs, IOI screws were a median (interquartile range) of 10 mm (7-11 mm) and 3 mm (0-4 mm) from the cortex, respectively. The sensitivity and specificity of radiographs to detect IOI screws was 39% and 92%, respectively. The incidence of osteonecrosis and revision surgeries in hips, with and without IOI screws, was 6% versus 6% [Odds ratio (OR) 1.1, 95% confidence interval (CI) 0.2-5.3] and 10% versus 10% (OR 1.0, CI 0.3-3.1), respectively; a true clinical difference cannot be excluded due to the width of the confidence intervals. CONCLUSIONS: There was a high incidence of IOI posterosuperior screws on CT scans. Postoperative radiographs had a poor sensitivity for detecting IOI screws. A larger sample size is necessary to evaluate the association of IOI screws with osteonecrosis and revision surgery. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy.

BACKGROUND: It is unknown whether subscapularis management technique has an influence on the outcomes and complications of stemless total shoulder arthroplasty. The purpose of this study, therefore, was to compare outcomes and complications between subscapularis tenotomy, peel, and lesser tuberosity osteotomy used during stemless shoulder arthroplasty. METHODS: We reviewed 188 stemless anatomic total shoulder arthroplasties and compared clinical and functional outcomes between those performed through a subscapularis tenotomy (n = 68), subscapularis peel (n = 65), or lesser tuberosity osteotomy (n = 55). Patients were followed up clinically and radiographically at 6 months, 1 year, and 2 years postoperatively. RESULTS: At 2 years postoperatively, no statistically significant differences in visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, or patient-reported instability (P ≥ .19) were found between groups. Active external rotation was greater in the peel group (P = .006) than in the tenotomy group but was not different compared with the lesser tuberosity osteotomy group (P = .07). No statistically significant difference in clinical subscapularis failures was noted between groups (P = .11); however, 2 patients in the peel group sustained a subscapularis failure requiring reoperation. DISCUSSION: The results of this multicenter comparative analysis show that all 3 subscapularis management techniques are effective and safe in the short term when used with stemless anatomic total shoulder arthroplasty.

Assessing glenosphere position: superior approach versus deltopectoral for reverse shoulder arthroplasty.

BACKGROUND: The anterosuperior (AS) approach for reverse total shoulder arthroplasty (RTSA) has been reported as a risk factor for baseplate malposition because of potential difficulty in glenoid exposure. The objective of this study was to compare glenoid baseplate position between the AS and deltopectoral (DP) approaches in relation to the surgeon's experience and to evaluate the effect of placement on clinical outcomes. METHODS: There were 109 shoulders that underwent RTSA for cuff tear arthropathy or osteoarthritis with cuff tearing by a single surgeon. The AS approach was used in 87 shoulders. Clinical, radiographic, and functional outcomes were assessed for all patients with a minimum of 2 years of follow-up. Initial postoperative radiographs of all 109 shoulders were assessed for baseplate positioning. RESULTS: The mean change in glenoid inclination was 3.0° inferior with the AS approach and 2.5° inferior with the DP approach (P = .68). Pain scores (P = .14), range of motion, and American Shoulder and Elbow Surgeons scores (P = .16) improved in both groups, without a difference between approach. Scapular notching was noted in 68.5% of AS shoulders and 72.4% of DP shoulders (P = .78). Over time, there was a trend to place the glenoid baseplate more caudal with less inferior tilt. DISCUSSION AND CONCLUSION: Both approaches produce similar baseplate position, clinical outcomes, and rates of scapular notching when they are used for RTSA. Attempts to inferiorize the glenoid baseplate through the AS approach may increase the risk of superior inclination.

Shoulder arthroplasty following gastric bypass, do complications follow?

INTRODUCTION: Previous reports have shown an increased risk of complications after arthroplasty in the obese population. It remains unclear if gastric bypass surgery prior to shoulder arthroplasty modifies the complication and failure rate. The purpose of this study is to assess the complication and re-operation rates following shoulder arthroplasty in this population. METHODS: Between 2002 and 2012, 39 shoulders with prior gastric bypass underwent shoulder arthroplasty (3 HA, 16 TSA, 20 RSA). The mean time from the gastric bypass to arthroplasty was 13 years (range, 0.7-32). Shoulders were followed for a minimum of two years (mean, 3.8 years) or until re-operation. Outcome measures included pain, range of motion, satisfaction, modified Neer ratings, and ASES scores. RESULTS: Complications occurred in seven shoulders (18%), with five requiring re-operation. There was no common failure mechanism. Re-operations occurred for aseptic glenoid loosening, periprosthetic fracture, and unexplained pain. Those shoulders with complications were similar to those without in regard to age, sex, and BMI. Complications were more common following anatomic arthroplasty compared to reverse arthroplasty (5 vs 1, p = 0.06); however, complications were not improved compared to historical controls with morbid obesity. Overall, pain improved significantly from 4.8 pre-operatively to 2.3 postoperatively (p < 0.001). All groups, regardless of arthroplasty type, demonstrated significant improvements in forward elevation and external rotation. CONCLUSION: Gastric bypass surgery prior to shoulder arthroplasty leads to clinical improvement in both pain and range of motion. Prior gastric bypass surgery does not result in a lower surgical complication rate compared to previously published reports in the morbidly obese population. LEVEL OF EVIDENCE: Level 4, case series.