Chemical editing of proteoglycan architecture.

Proteoglycans are heterogeneous macromolecular glycoconjugates that orchestrate many important cellular processes. While much attention has focused on the poly-sulfated glycosaminoglycan chains that decorate proteoglycans, other important elements of their architecture, such as core proteins and membrane localization, have garnered less emphasis. Hence, comprehensive structure-function relationships that consider the replete proteoglycan architecture as glycoconjugates are limited. Here we present an extensive approach to study proteoglycan structure and biology by fabricating defined semisynthetic modular proteoglycans that can be tailored for cell surface display. The expression of proteoglycan core proteins with unnatural amino acids permits bioorthogonal click chemistry with functionalized glycosaminoglycans for methodical dissection of the parameters required for optimal binding and function of various proteoglycan-binding proteins. We demonstrate that these sophisticated materials can recapitulate the functions of native proteoglycan ectodomains in mouse embryonic stem cell differentiation and cancer cell spreading while permitting the analysis of the contributing architectural elements toward function.

Measure what matters: Single Assessment Numeric Evaluation (SANE) score as the critical measure for shoulder outcomes.

BACKGROUND: Implementation of a system anchored in patient outcomes is challenged to gain widespread adoption required to demonstrate the value of care provided for shoulder conditions. This is in large part because of the administrative burden created by current tools and clinical implementation barriers that limit practical use and therefore leave most clinicians, administrators, payers, and patients without a measure of what matters most: Are patients improving? Thus, we must ask ourselves, How do we accurately and efficiently measure and report quality of care in a simple, reliable, and easily communicated manner? We propose that the Single Assessment Numeric Evaluation (SANE) score is the best solution to measure patient improvement and can be used universally for all shoulder conditions. The measure is simple, valid, reliable, and sensitive to change and has the lowest implementation barrier compared with all other outcome measures. METHODS: We synthesized the available literature (11 studies) that demonstrates strong psychometrics comparable to legacy measures across >4000 patients with a wide range of shoulder conditions. RESULTS: SANE scores range from 40% to 60% at baseline for most patients before treatment and range from 75% to 85% at 1 year after therapy depending on the condition, similar to legacy scores such as the American Shoulder and Elbow Surgeons score. Additionally, the SANE score shows similar baseline and post-care measures across conditions that can be used to guide clinical care. This finding shows that the observed baseline and improvement scores can provide valuable patient assessment and can be used in aggregate for quality improvement and other value-based purposes. CONCLUSION: We strongly recommend the SANE score as the primary patient outcome measure for patients with all shoulder conditions, given the value of measuring every patient's progress and growing pressure to quantify patient outcomes.

Mapping glycan-mediated galectin-3 interactions by live cell proximity labeling.

Galectin-3 is a glycan-binding protein (GBP) that binds ß-galactoside glycan structures to orchestrate a variety of important biological events, including the activation of hepatic stellate cells and regulation of immune responses. While the requisite glycan epitopes needed to bind galectin-3 have long been elucidated, the cellular glycoproteins that bear these glycan signatures remain unknown. Given the importance of the three-dimensional (3D) arrangement of glycans in dictating GBP interactions, strategies that allow the identification of GBP receptors in live cells, where the native glycan presentation and glycoprotein expression are preserved, have significant advantages over static and artificial systems. Here we describe the integration of a proximity labeling method and quantitative mass spectrometry to map the glycan and glycoprotein interactors for galectin-3 in live human hepatic stellate cells and peripheral blood mononuclear cells. Understanding the identity of the glycoproteins and defining the structures of the glycans will empower efforts to design and develop selective therapeutics to mitigate galectin-3-mediated biological events.

Contextualised high-intensity running profiles of elite football players with reference to general and specialised tactical roles.

The present study aimed to contextualise physical metrics with tactical actions according to general and specialised tactical roles. A total of 244 English Premier League players were analysed by coding player's physical-tactical actions via the fusion of tracking data and video. Data were analysed across 5 general (Central Defensive Players = CDP, Wide Defensive Players = WDP, Central Midfield Players = CMP, Wide Offensive Players = WOP, Central Offensive Players = COP) and 11 specialised positions (Centre Backs = CB, Full-Backs = FB, Wing-Backs = WB, Box-to-Box Midfielders = B2BM, Central Defensive Midfielders = CDM, Central Attacking Midfielders = CAM, Wide Midfielders = WM, Wide Forwards = WF, Centre Forwards = CF). COP covered more distance at high-intensity (> 19.8 km · h-1) when performing actions such as 'Break into Box', Run in Behind/Penetrate', and 'Close Down/Press' than other positions (ES: 0.6-5.2, P < 0.01). WOP covered more high-intensity 'Run with Ball' distance (ES: 0.7-1.7, P < 0.01) whereas WDP performed more 'Over/Underlap' distance than other positions (ES: 0.9-1.4, P < 0.01). CDP and WDP covered more high-intensity 'Covering' distances than other positions (ES: 0.4-2.4, P < 0.01). Nonetheless, data demonstrated that implementing specialised positional analysis relative to a generalised approach is more sensitive in measuring physical-tactical performances of players with the latter over or underestimating the match demands of the players compared to the former. A contextualised analysis may assist coaches and practitioners when designing position or even player-specific training drills since the data provides unique physical-tactical trends across specialised roles.

Tier-specific contextualised high-intensity running profiles in the English Premier League: more on-ball movement at the top.

The present study aimed to determine the physical-tactical profiles of elite football teams and individual players according to final league rankings. A total of 50 English Premier League matches (n = 100 match and 583 player observations) were analysed by coding the player's physical-tactical actions through synchronising tracking data and video. Final league rankings were categorised into Tiers: (A) 1st-5th ranking (n = 25), (B) 6th-10th ranking (n = 26), (C) 11th-15th ranking (n = 26), and (D) 16th-20th ranking (n = 23). One-way analyses of variance were used to compare match performances between different Tiers, and effect size (ES) was determined for the meaningfulness of the difference. Tier A teams covered 39-51% more high-intensity distance for 'Move to Receive/Exploit Space' (ES: 1.3-1.6, P < 0.01) and 'Run with Ball' (ES: 0.9-1.0, P < 0.05) than Tier C and D, and 23-94% more distance for 'Over/Underlap' (ES: 1.0, P < 0.01), 'Run in Behind/Penetrate' (ES: 0.7, P < 0.05), and 'Break into Box' (ES: 0.9, P < 0.05) compared to Tier C. Central and Wide Defensive Players in Tier A covered 65-551% more high-intensity 'Move to Receive/Exploit Space' distance compared to other Tiers (ES: 0.6-1.0, P < 0.01). Moreover, the additional options within the physical-tactical actions and zonal differences unveiled more meaningful insights into 'HOW' the top Tier teams physically and tactically perform. Thus, the amalgamated physical-tactical data help improve our understanding of a team's playing style relative to their competitive standard.

Activation of Crtc2/Creb1 in skeletal muscle enhances weight loss during intermittent fasting.

The Creb-Regulated Transcriptional Coactivator (Crtc) family of transcriptional coregulators drive Creb1-mediated transcription effects on metabolism in many tissues, but the in vivo effects of Crtc2/Creb1 transcription on skeletal muscle metabolism are not known. Skeletal muscle-specific overexpression of Crtc2 (Crtc2 mice) induced greater mitochondrial activity, metabolic flux capacity for both carbohydrates and fats, improved glucose tolerance and insulin sensitivity, and increased oxidative capacity, supported by upregulation of key metabolic genes. Crtc2 overexpression led to greater weight loss during alternate day fasting (ADF), selective loss of fat rather than lean mass, maintenance of higher energy expenditure during the fast and reduced binge-eating during the feeding period. ADF downregulated most of the mitochondrial electron transport genes, and other regulators of mitochondrial function, that were substantially reversed by Crtc2-driven transcription. Glucocorticoids acted with AMPK to drive atrophy and mitophagy, which was reversed by Crtc2/Creb1 signaling. Crtc2/Creb1-mediated signaling coordinates metabolic adaptations in skeletal muscle that explain how Crtc2/Creb1 regulates metabolism and weight loss.

Autograft Long Head Biceps Tendon Can Be Used as a Scaffold for Biologically Augmenting Rotator Cuff Repairs.

PURPOSE: We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs. METHODS: The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose-derived mesenchymal stromal cells (ADMSCs) was also determined. RESULTS: Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [-.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte-like phenotype, as indicated by an 8.7× increase in scleraxis (P = .040) and a 3.6× increase in collagen type III mRNA expression (P = .050) compared with undifferentiated ADMSC controls. CONCLUSIONS: The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated. CLINICAL RELEVANCE: This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.

Contextualised peak periods of play in English Premier League matches.

The present study aimed to determine the physical-tactical trends of elite players/teams during peak 1-, 3- and 5-min periods of match-play. A total of 50 English Premier League matches (n = 583 player observations) were analysed by coding the players' physical-tactical activities through the synchronisation of tracking data and video. The contextualised data showed that during the peak periods (i.e., the most demanding passage of play), players/teams covered the largest distances for 'Recovery Run' (28-37%) out of possession and 'Support Play' (9-13%) in possession. In the following periods, players covered less high-intensity distance versus the average with a more pronounced decline in the next 1-min period than longer duration 3- and 5-min periods (48% vs ~25-30%, ES: 0.4-0.5, P < 0.01); team data showed similar trends with different relative patterns (31% vs 17-30%, ES: 0.5-0.8, P < 0.01). After peak periods, players/teams performed 20-53% less high-intensity distances for 'Covering' and 'Recovery Run' (ES: 0.2-0.7, P < 0.01) out of possession. However, players covered 28-91% less distance for 'Run with Ball' (ES: 0.1-0.5, P < 0.05) when in possession. Some physical-tactical actions exhibited inconsistency in different time durations of the next periods; however, these physical-tactical data were position-specific. This may signify that each position has certain physical-tactical actions to execute even after the peak periods, especially when they are tactically required to do so. As the data demonstrates unique physical-tactical trends of players/teams during the peak and next periods of play, this could help practitioners prescribe position- and player-specific drills, and better understand transient decrements in high-intensity running after intense passages of play.

Is residual tendon a predictor of outcome following arthroscopic rotator cuff repair? A preliminary outlook at short-term follow-up.

BACKGROUND: Multiple factors including muscle atrophy, fatty infiltration, smoking, advanced patient age, and increasing tear size have been identified as risk factors for retear after rotator cuff repair. However, little is known about what effect the length of the residual rotator cuff tendon has on the success of repair and patient outcomes. METHODS: This study included 64 patients. Patients were stratified based on a residual tendon length of greater than 15 mm (group 1, residual tendon) or 15 mm or less (group 2, no residual tendon). Rotator cuff tendon integrity was then evaluated using ultrasound imaging at 6 months. Outcome measures included the Single Assessment Numeric Evaluation score, visual analog scale score, EQ5D Index score, Global Rating of Change score, and Penn Shoulder Score. RESULTS: No differences were found between groups regarding demographic data or repair configuration. Assessment of tendon healing demonstrated an increased rate of tendons that had "not healed" in group 2 (19.3% [n = 5] vs. 13.2% [n = 5]), but this difference was not statistically significant (P = .55). Functional outcome scores improved significantly from preoperatively to final follow-up in both groups and displayed no differences at 6-month follow-up. CONCLUSION: A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. Although there was a trend toward a decreased rate of healing in patients with smaller residual tendons, this was not significant.

Management of Three- and Four-Part Proximal Humerus Fractures.

The management of three- and four-part proximal humerus fractures remains controversial because the literature has supported all forms of management, including nonsurgical management, open reduction and internal fixation (ORIF), and shoulder arthroplasty. Specific patient factors ultimately influence the decision of which treatment best fits the patient and the fracture. Surgeons should understand the rationale for nonsurgical and surgical management of these fractures, including ORIF and reverse shoulder arthroplasty.

Creb coactivators direct anabolic responses and enhance performance of skeletal muscle.

During the stress response to intense exercise, the sympathetic nervous system (SNS) induces rapid catabolism of energy reserves through the release of catecholamines and subsequent activation of protein kinase A (PKA). Paradoxically, chronic administration of sympathomimetic drugs (ß-agonists) leads to anabolic adaptations in skeletal muscle, suggesting that sympathetic outflow also regulates myofiber remodeling. Here, we show that ß-agonists or catecholamines released during intense exercise induce Creb-mediated transcriptional programs through activation of its obligate coactivators Crtc2 and Crtc3. In contrast to the catabolic activity normally associated with SNS function, activation of the Crtc/Creb transcriptional complex by conditional overexpression of Crtc2 in the skeletal muscle of transgenic mice fostered an anabolic state of energy and protein balance. Crtc2-overexpressing mice have increased myofiber cross-sectional area, greater intramuscular triglycerides and glycogen content. Moreover, maximal exercise capacity was enhanced after induction of Crtc2 expression in transgenic mice. Collectively these findings demonstrate that the SNS-adrenergic signaling cascade coordinates a transient catabolic stress response during high-intensity exercise, which is followed by transcriptional reprogramming that directs anabolic changes for recovery and that augments subsequent exercise performance.

Longitudinal assessments in continuing specialty certification and lifelong learning.

Longitudinal assessment (LA) involves the regular, spaced delivery of a limited number of questions on practice relevant content on a computer or mobile internet platform. Depending on the platform, participants may indicate relevance of the content to their practice and confidence in their answer prior to receiving immediate feedback (including critiques) on each question. Individual dashboards may be included to assist participants in tracking progress and identifying areas of strength and weaknesss across a content blueprint. This paper provides an overview of the theoretical underpinnings underlying LA programs, briefly describes current uses of LA in medicine and suggests areas for evaluating the role of LA in continuing medical specialty certification and continuing professional development.

Selection, implementation, and interpretation of patient-centered shoulder and elbow outcomes.

The movement toward a value-based health care market requires comparison of physicians, hospitals, and health systems. Traditionally, process-based measures such as infection and readmission rates have been used. However, these events are uncommon in shoulder and elbow surgery, thus limiting their utility. Patient-reported outcomes (PROs) are a promising measure of quality and have been proposed as a potential metric to compare surgeon performance. However, there are over 25 different PROs for shoulder and elbow conditions. Therefore, the American Shoulder and Elbow Surgeons Value Committee was established to recommend shoulder and elbow PROs in an effort to align their implementation for quality assessment. The committee developed criteria for assessing the outcome measures including that each measure should be patient reported, not requiring clinician input; have published validation and psychometrics; and be standardized and demonstrate ease of use for the patient and clinician. Two sets were suggested: one set for clinical implementation and a more robust set for research purposes. The final recommendation was that all patients should complete the Veterans Rand 12 for general health and the Single Assessment Numeric Evaluation for the specified body region. For patients with shoulder complaints, the American Shoulder and Elbow Surgeons score was recommended, and for those with elbow complaints, the Quick Disabilities of the Arm, Shoulder and Hand score was recommended. More robust disease-specific measures were provided for research purposes. Continued efforts should be made to align these measures across orthopedics to facilitate use of patient outcome measures as a component of value-based health care assessment.

Preventing infection in shoulder surgery.

Although rare, infection after shoulder surgery can represent a devastating complication. Infection can negatively affect clinical outcomes, and eradication often requires a protracted treatment course. Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes are among the most frequently isolated pathogens. Perioperative measures can be implemented to reduce infection risk. Here we review various perioperative practices and their efficacy at reducing infection after shoulder surgery.

Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review.

BACKGROUND: This systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty. METHODS: Searches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores. RESULTS: The 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favored the ST group (80.8) over the SP (79.1) and LTO (73) groups. CONCLUSIONS: The data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favor the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.

Clinical outcomes of suprascapular nerve decompression: a systematic review.

BACKGROUND: Suprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications. METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews. RESULTS: Twenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies. CONCLUSIONS: Surgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.

Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques.

BACKGROUND: Pseudoparalysis remains one of the most challenging conditions in shoulder surgery. Long thought of as an unsolvable problem, recent advances in surgical techniques offer potential return of overhead motion in the setting of massive irreparable rotator cuff tears. This article summarizes the available literature including existing definitions and the results of different treatment approaches regarding range of motion, outcome scores, and reversal. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the MEDLINE database, Cochrane database, Physiotherapy Evidence Database, and Google Scholar database was performed for studies that defined a preoperative shoulder group as having pseudoparalysis. A secondary search included preoperative active forward elevation less than 90°. RESULTS: In 16 studies, the most consistent definition was a massive rotator cuff tear with active elevation less than 90°, but studies inconsistently included stiffness, external rotation loss, arthritic changes, neurologic status, and pain. There were 6 different techniques: nonoperative rehabilitation, rotator cuff repair, muscle transfer, hemiarthroplasty, reverse total shoulder arthroplasty, and reverse total shoulder arthroplasty with muscle transfer. Postoperatively, all approaches showed improvement. CONCLUSION: Pseudoparalysis of the shoulder has a variable definition in the literature without consideration of degree or substratification of other confounders such as the presence of arthritis or pain. Thus the literature supports treating this condition with any variety of treatment. We propose that pseudoparalysis be more restrictively defined to allow comparisons. In addition, we propose an algorithm to serve as a treatment guideline to aid in surgical decision making for this condition.

A comparison of onlay versus inlay glenoid component loosening in total shoulder arthroplasty.

BACKGROUND: Glenoid component loosening is common in total shoulder arthroplasty (TSA), often resulting from the mechanical interaction of glenohumeral components. This cadaveric study was performed to evaluate and to compare commercially available onlay and inlay glenoid prosthetic designs with respect to loading characteristics and loosening. METHODS: Sixteen prescreened cadaveric shoulders (8 matched pairs) underwent either onlay or inlay TSA. We created a custom glenohumeral loading model and used cycles of 5 mm anterior-posterior humeral translation to simulate a rocking-horse loosening mechanism for all testing. Articular TekScan measurements were performed with 9.1 kg (88.9 N) of glenohumeral compression before and after TSA. Fatigue testing was performed with 34.0 kg (333.6 N) of glenohumeral compression using high-definition video to document gross glenoid loosening. Testing ended with gross loosening or a maximum of 4000 cycles. Mean contact area, pressure, and joint reaction force were used to compare the 2 glenoid designs. RESULTS: In both implant types, contact area decreased and pressure increased after TSA (P < .0001). Force increased at the onlay component edge only (P = .0012) compared with native glenoid testing. Force was greater in the onlay vs. the inlay implants (P < .0001). During fatigue testing, all onlay glenoid components exhibited gross loosening at a mean of 1126 cycles (range, 749-1838), whereas none of the inlay glenoid components exhibited gross loosening (P < .0001). CONCLUSION: The inlay glenoid implant exhibited biomechanical characteristics favoring stability and decreased loosening compared with the onlay glenoid implant in this cadaveric model.

Outcomes of total shoulder arthroplasty in patients younger than 65 years: a systematic review.

BACKGROUND: Despite concerns about the longevity of total shoulder arthroplasty (TSA) in young patients, it remains an attractive option because of the absence of superior options. METHODS: A systematic review was performed using searches of PubMed, Embase, and Cochrane databases. English-language studies were identified with search terms "total shoulder arthroplasty" (title/abstract) or "shoulder replacement" (title/abstract) and "young" (title/abstract) or "under 65 years of age" (title/abstract). Duplicate studies, studies not reporting outcomes, and those using a humeral resurfacing technique were excluded. Outcomes of interest included pain, range of motion, patient-reported outcome scores, patient satisfaction, radiographic changes, complication and revision rates, and implant survival. RESULTS: Six studies met inclusion criteria. Significant improvements in pain, range of motion, and patient-reported outcomes were found across all studies that reported these measures. At an average of 9.4 years, 17.4% underwent revision and 54% had glenoid lucency. Whereas glenoid loosening is the most common reason for revision (52%), overall implant survivorship was reported at 60% to 80% at 10- to 20-year follow-up. Outcome measures including the Constant, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores were reported, with generally satisfactory but not excellent results between 3 and 10 years from surgery. CONCLUSIONS: Although there is concern with periprosthetic radiolucency and glenoid loosening in the young patient (<65 years) undergoing TSA, overall low revision rates and high implant survivorship are reported in the current literature. Whereas the patient-reported outcomes are inferior to those of the overall TSA population, there is significant improvement from baseline levels in young patients with glenohumeral arthritis.

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial.

BACKGROUND: Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB). METHODS: This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05. RESULTS: Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different. CONCLUSION: Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.