Diabetes mellitus and serum organochlorine pesticides mixtures in Mexican women.

BACKGROUND: Very recently, it has been reported that exposure to different mixtures of organochlorine pesticides (OCP) is associated with the development of diabetes mellitus (DM). In Mexico, DM is a public health problem that might be related to the historical intense use of OCP. We aimed to evaluate, the association between DM and serum concentrations of OCP mixtures, and identify the main contributors within them. METHODS: We conducted a secondary cross-sectional analysis on the control group from a breast cancer population-based case-control study conducted from 2007 to 2011 in Northern Mexico. We identified 214 self-reported diabetic women and 694 non-diabetics. We obtained direct information about sociodemographic, lifestyle and reproductive characteristics. We determined 24 OCP and metabolites in serum by gas chromatography using an electron capture micro detector. We used Weighted Quantile Sum regression to assess the association of DM and exposure to multiple OCP, and the contribution of each compound within the mixture. RESULTS: We found a positive adjusted association between DM and an OCP mixture (OR: 2.63, 95%CI: 1.85, 3.74), whose primary contribution arose from p, p'-DDE (mean weight 23.3%), HCB (mean weight 17.3%), trans nonachlor (mean weight 15.4%), o, p'-DDE (mean weight 7.3%), heptachlor epoxide (mean weight 5.9%), oxychlordane (mean weight 4.7%), and heptachlor (mean weight 4.5%). In addition, these OCP along with p, p'-DDT and cis chlordane, were of concern and remained associated when excluding hypertensive women from the analysis (OR 2.55; 95% CI 1.56, 4.18). CONCLUSIONS: Our results indicate, for the first time in a Latin-American population, that the concomitant exposure to multiple OCP is associated with DM. Further research is needed since the composition of OCP mixtures may vary according to regional pesticides use patterns.

Modeling microgel swelling: Influence of chain finite extensibility.

Microgels exhibit the ability to undergo reversible swelling in response to shifts in environmental factors that include variations in temperature, concentration, and pH. While several models have been put forward to elucidate specific aspects of microgel swelling and its impact on bulk behavior, a consistent theoretical description that chains throughout the microscopic degrees of freedom with suspension properties and deepens into the full implications of swelling remains a challenge yet to be met. In this work, we extend the mean-field swelling model of microgels from Denton and Tang [J. Chem. Phys. 145, 164901 (2016)] to include the finite extensibility of the polymer chains. The elastic contribution to swelling in the original work is formulated for Gaussian chains. By using the Langevin chain model, we modify this elastic contribution in order to account for finite extensibility effects, which become prominent for microgels containing highly charged polyelectrolytes and short polymer chains. We assess the performance of both elastic models, namely for Gaussian and Langevin chains, comparing against coarse-grained bead-spring simulations of ionic microgels with explicit electrostatic interactions. We examine the applicability scope of the models under a variation of parameters, such as ionization degree, microgel concentration, and salt concentration. The models are also tested against experimental results. This work broadens the applicability of the microgel swelling model toward a more realistic description, which brings advantages when describing the suspensions of nanogels and weak-polyelectrolyte micro-/nanogels.

Greater Socioeconomic Disadvantage as Measured by the Area Deprivation Index Is Associated With Failure of Healing Following Arthroscopic Repair of Massive Rotator Cuff Tears but Not With Clinical Outcomes.

PURPOSE: To analyze the relationship between Area Deprivation Index (ADI) and preoperative status and short-term postoperative clinical outcomes among patients who underwent arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCTs). METHODS: A retrospective review was conducted on prospectively maintained data on patients who underwent ARCR of MRCTs defined as tear size ≥5 cm or complete tear of at least 2 tendons, with a minimum 2-year follow-up and a valid home address between January 2015 and December 2018. Each patient's home address was mapped to the ADI to determine neighborhood disadvantage. This composite index is composed of 17 census-based indicators, including income, education, employment, and housing quality to quantify the level of socioeconomic deprivation. Ratings were recorded and categorized based on the sample's percentile. Patients were then divided into 2 groups: upper quartile (ie, most disadvantaged [≥75th percentile]) and lower 3 quartiles (ie, least disadvantaged [<75th percentile]). Bivariate analysis was performed to associate ADI with patient-reported outcomes (PROs) and range of motion pre- and postoperatively, as well as complications, healing rate, satisfaction, and return to work. Patients reaching or exceeding the minimal clinically important difference for visual analog scale (VAS), American Shoulder and Elbow Surgeons, Veterans Rand 12-Item questionnaire, and subjective shoulder value were recorded for both cohorts. RESULTS: Ninety-nine patients were eligible for study analysis. Preoperative PROs and range of motion were similar, except for a greater VAS for pain (6.3 vs 4.3; P < .01) and lower American Shoulder and Elbow Surgeons score (32.2 vs 45.1; P = .01) in the most disadvantaged group. Both groups showed similar postoperative PROs scores, but greater VAS improvement was seen in the upper quartile group (Δ 4.2 vs Δ 3.0; P = .04). In contrast, only the least-disadvantaged group significantly improved in internal rotation (P = .01) and forward flexion (18°; P < .01) from baseline. Although satisfaction, complications, and return to work were comparable (P > .05), failure of healing occurred more frequently in the most disadvantaged group (21% vs 6%; P = .03). CONCLUSIONS: Patients with MRCTs residing in the most disadvantaged neighborhoods as measured by the ADI have more pain and functional limitations before undergoing ARCR but demonstrate similar postoperative functional improvements to patients from other socioeconomic backgrounds. Failure of healing of MRCTs may be more common in disadvantaged groups. Furthermore, both groups reported similar rates of clinically important functional improvement. LEVEL OF EVIDENCE: Level III, retrospective cohort comparison.

Quantifying Threshold Scores for Patient Satisfaction After Massive Rotator Cuff Repair for the Interpretation of Mid-Term Patient-Reported Outcomes.

PURPOSE: To establish minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values for 4 patient-reported outcomes (PROs) in patients undergoing arthroscopic massive rotator cuff repair (aMRCR): American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), Veterans Rand-12 (VR-12) score, and the visual analog scale (VAS) pain. In addition, our study seeks to determine preoperative factors associated with achieving clinically significant improvement as defined by the MCID and PASS. METHODS: A retrospective review at 2 institutions was performed to identify patients undergoing aMRCR with minimum 4-year follow-up. Data collected at the 1-year, 2-year, and 4-year time points included patient characteristics (age, sex, length of follow-up, tobacco use, and workers' compensation status), radiologic parameters (Goutallier fatty infiltration and modified Collin tear pattern), and 4 PRO measures (collected preoperatively and postoperatively): ASES score, SSV, VR-12 score, and VAS pain. The MCID and PASS for each outcome measure were calculated using the distribution-based method and receiver operating characteristic curve analysis, respectively. Pearson and Spearman coefficient analyses were used to determine correlations between preoperative variables and MCID or PASS thresholds. RESULTS: A total of 101 patients with a mean follow-up of 64 months were included in the study. The MCID and PASS values at the 4-year follow-up for ASES were 14.5 and 69.4, respectively; for SSV, 13.7 and 81.5; for VR-12, 6.6 and 40.3; and for VAS pain, 1.3 and 1.2. Greater infraspinatus fatty infiltration was associated with failing to reach clinically significant values. CONCLUSIONS: This study defined MCID and PASS values for commonly used outcome measures in patients undergoing aMRCR at the 1-year, 2-year, and 4-year follow-up. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Home-Based or Supervised Physical Therapy Show Similar Functional Outcomes and Healing After Massive Rotator Cuff Repair.

PURPOSE: This study aimed to compare postoperative clinical outcomes at the 3-month, 6-month, 12-month, and latest follow-up in patients undergoing supervised physical therapy (PT) or a home-based exercise program after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCTs). METHODS: A retrospective review was conducted on a prospectively maintained database of patients who underwent either supervised PT or home-based therapy after ARCR of MRCTs between January 2015 and December 2018 at a single center with a minimum 24-month follow-up. At their 2-week postoperative routine follow-up, patients are allowed to choose between home-based and supervised PT. Patient-reported outcomes (PROs) and range of motion (ROM) were collected and compared between cohorts preoperatively and at the 3-month, 6-month, 12-month, and latest follow-up. The percentage of patients reaching or exceeding the minimal clinically important difference (MCID) and patient accepted symptomatic state (PASS) for visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeon score (ASES), and Subjective Shoulder Value (SSV) were recorded for both cohorts at each time point. Complications, healing, satisfaction, and return to work were reported. Healing was evaluated via ultrasound at the latest follow-up. RESULTS: Ninety-nine patients met the study criteria: 61 in the supervised PT cohort, and 38 in the home-based cohort. The supervised PT and home-based cohorts returned to clinic for their most recent follow-up at 53±20 and 55±16 months (p=0.496) after surgery, respectively. There was no difference when comparing tendon involvement (SS, p=0.574; IS, p=0.288; SSc p=0.592), tear retraction (p=0.603), or high-grade fatty infiltration (SS, p=0.684; IS, p-0.397; SSc p=0.473) based on preoperative MRI assessment and surgery-related factors, including anterior (p=0.473) or posterior (p=0.386) slides, fixation constructs (p=0.829), or complete repair (p=0.912). Both cohorts showed similar PROs and ROM at baseline. Postoperative PROs and ROM were similar among groups at the 3-month, 6-month, 12-month, and latest follow-up. However, ASES (71.4 vs 61.2; p = 0.013) and FF (135° vs 118°; p = 0.023) were significantly higher at 3-month follow-up in the home-based cohort. Both groups comparably achieved MCID and PASS for PROs at the 3-month, 6-month, and12-month follow-up. At the latest follow-up, the supervised PT and home-based cohort achieved MCID and PASS for VAS (75% vs 81%, p=0.573; 70% vs 72%, p=0.911), ASES (76% vs 74%, p=0.777; 72% vs 72%, p=0.873), and SSV (82% vs 84%, p=0.734; 72% vs 66%, p=0.489), respectively. Satisfaction, healing, complication, and return to work rates were similar. CONCLUSION: Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. Although patients with home-based therapy achieved higher FF and ASES at the 3-month follow-up, these became comparable starting at the 6-month postoperative mark. MCID and PASS were achieved similarly for PROs at each time point.

Identification of ChatGPT-Generated Abstracts Within Shoulder and Elbow Surgery Poses a Challenge for Reviewers.

PURPOSE: To evaluate the extent to which experienced reviewers can accurately discern between AI-generated and original research abstracts published in the field of shoulder and elbow surgery and compare this to the performance of an AI-detection tool. METHODS: Twenty-five shoulder and elbow-related articles published in high-impact journals in 2023 were randomly selected. ChatGPT was prompted with only the abstract title to create an AI-generated version of each abstract. The resulting 50 abstracts were randomly distributed to and evaluated by 8 blinded peer reviewers with at least 5 years of experience. Reviewers were tasked with distinguishing between original and AI-generated text. A Likert scale assessed reviewer confidence for each interpretation and the primary reason guiding assessment of generated text was collected. AI output detector (0-100%) and plagiarism (0-100%) scores were evaluated using GPTZero. RESULTS: Reviewers correctly identified 62% of AI-generated abstracts and misclassified 38% of original abstracts as being AI-generated. GPTZero reported a significantly higher probability of AI output among generated abstracts (median 56%, IQR 51-77%) compared to original abstracts (median 10%, IQR 4-37%; p < 0.01). Generated abstracts scored significantly lower on the plagiarism detector (median 7%, IQR 5-14%) relative to original abstracts (median 82%, IQR 72-92%; p < 0.01). Correct identification of AI-generated abstracts was predominately attributed to the presence of unrealistic data/values. The primary reason for misidentifying original abstracts as AI was attributed to writing style. CONCLUSIONS: Experienced reviewers faced difficulties in distinguishing between human and AI-generated research content within shoulder and elbow surgery. The presence of unrealistic data facilitated correct identification of AI abstracts, whereas misidentification of original abstracts was often ascribed to writing style.

Robert H. Cofield, MD, Award for Best Oral Presentation 2023: Up to 8 mm of glenoid-sided lateralization does not increase the risk of acromial or scapular spine stress fracture following reverse shoulder arthroplasty with a 135° inlay humeral component.

BACKGROUND: Glenoid-sided lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of acromial or scapular spine fractures (ASFs). The purpose of this study was to assess if glenoid-sided lateralization even up to 8 mm increases the risk for stress fracture following RSA with a 135° inlay humeral component. METHODS: A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. Varying amounts of glenoid lateralization were used from 0 to 8 mm. Preoperative radiographs were reviewed for the presence of acromial thinning, acromiohumeral distance (AHD), and inclination. Postoperative implant position (distalization, lateralization, and inclination) as well as the presence of ASF was evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on component and clinical variables to assess for factors predictive of ASF. RESULTS: Acromial or scapular spine fractures were identified in 26 of 470 shoulders (5.5%). Glenoid-sided lateralization was not associated with ASF risk (P = .890). Furthermore, the incidence of fracture did not vary based on glenoid-sided lateralization (0-2 mm, 7.4%; 4 mm, 5.6%; 6 mm, 4.4%; 8 mm, 6.0%; P > .05 for all comparisons). RSA on the dominant extremity was predictive of fracture (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.20-5.75; P = .037), but there was no relationship between patient age, sex, preoperative acromial thinning, or diagnosis and risk of fracture. Although there was no difference in mean postoperative AHD between groups (P = .443), the pre- to postoperative delta AHD was higher in the stress fracture group (2.0 ± 0.7 cm vs. 1.7 ± 0.7 cm; P = .015). For every centimeter increase in delta AHD, there was a 121% increased risk for fracture (OR 2.21, 95% CI 1.33-3.68; P = .012). Additionally, for every 1-mm increase in inferior glenosphere overhang, there was a 19% increase in fracture risk (P = .025). CONCLUSION: Up to 8 mm of glenoid-sided metallic lateralization does not appear to increase the risk of ASF when combined with a 135° inlay humeral implant. Humeral distalization increases the risk of ASF, particularly when there is a larger change between pre- and postoperative AHD or higher inferior glenosphere overhang. In cases of pronounced preoperative superior humeral migration, it may be a consideration to avoid excessive postoperative distalization, but minimizing bony impingement via glenoid-sided lateralization appears to be safe.

Predicting academic productivity among American Shoulder and Elbow Surgeons fellowship faculty from publications acquired before and during surgical training.

BACKGROUND: Orthopedic residency and fellowship applicants with a strong research record are highly valued for their potential in continuing academic excellence. Despite this, the association between research productivity during training and future academic productivity as an attending orthopedic surgeon is not well-established. We assess the effects of research output during different periods of surgical training as well as residency location on long-term academic productivity as an attending shoulder and elbow surgeon. METHODS: A search of the 2022-2023 American Shoulder and Elbow Surgeons Fellowship Directory was conducted to identify a list of orthopedic shoulder and elbow fellowship faculty members. Each surgeon's residency, fellowship and current institution of practice were determined and stratified by geographic location. Total publication counts acquired before residency, during residency, during fellowship, and after fellowship were collected for each faculty member. Attending publication rates and H-indices were calculated. A multivariate linear regression model was created, and significance was set at a P value <.05. RESULTS: A total of 149 shoulder and elbow fellowship faculty members representing 34 fellowship programs were identified. The average number of total publications per surgeon was 88.8 ± 102. The average attending publication rate was 5.29 ± 6.89 publications per year. The average H-index for included surgeons was 27.8 ± 24.4. The number of publications acquired before residency (ß = 0.293; P < .001), during residency (ß = 0.110; P = .025) and during fellowship (ß = 0.593; P < .001) were significantly associated with an increased attending publication rate, but no association was observed with the H-index [before residency (ß = -0.221; P = .574), during residency (ß = 0.045; P = .866), during fellowship (ß = 0.198; P = .678)]. There were no significant differences in total publication count (P = .397), attending publication rate (P = .237), or H-index (P = .364) based on location of residency training. DISCUSSION: Research output before and during surgical training is predictive of continued academic productivity as a shoulder and elbow surgeon. In particular, greater productivity during surgical fellowship was most predictive of academic output as an attending. While long-term academic productivity does not seem to be influenced by the geographic location of residency training, attending surgeons practicing in the Midwest had significantly greater total publication counts and H-indices but similar annual publication rates.

3-dimensionally printed patient-specific glenoid drill guides vs. standard nonspecific instrumentation: a randomized controlled trial comparing the accuracy of glenoid component placement in anatomic total shoulder arthroplasty.

BACKGROUND: Traditional, commercially sourced patient-specific instrumentation (PSI) systems for shoulder arthroplasty improve glenoid component placement but can involve considerable cost and outsourcing delays. The purpose of this randomized controlled trial was to compare the accuracy of glenoid component positioning in anatomic total shoulder arthroplasty (aTSA) using an in-house, point-of-care, 3-dimensionally (3D) printed patient-specific glenoid drill guide vs. standard nonspecific instrumentation. METHODS: This single-center randomized controlled trial included 36 adult patients undergoing primary aTSA. Patients were blinded and randomized 1:1 to either the PSI or the standard aTSA guide groups. The primary endpoint was the accuracy of glenoid component placement (version and inclination), which was determined using a metal-suppression computed tomography scan taken between 6 weeks and 1 year postoperatively. Deviation from the preoperative 3D templating plan was calculated for each patient. Blinded postoperative computed tomography measurements were performed by a fellowship-trained shoulder surgeon and a musculoskeletal radiologist. RESULTS: Nineteen patients were randomized to the patient-specific glenoid drill guide group, and 17 patients were allocated to the standard instrumentation control group. There were no significant differences between the 2 groups for native version (P = .527) or inclination (P = .415). The version correction was similar between the 2 groups (P = .551), and the PSI group was significantly more accurate when correcting version than the control group (P = .042). The PSI group required a significantly greater inclination correction than the control group (P = .002); however, the 2 groups still had similar accuracy when correcting inclination (P = .851). For the PSI group, there was no correlation between the accuracy of component placement and native version, native inclination, or the Walch classification of glenoid wear (P > .05). For the control group, accuracy when correcting version was inversely correlated with native version (P = .033), but accuracy was not correlated with native inclination or the Walch classification of glenoid wear (P > .05). The intraclass correlation coefficient was 0.703 and 0.848 when measuring version and inclination accuracy, respectively. CONCLUSION: When compared with standard instrumentation, the use of in-house, 3D printed, patient-specific glenoid drill guides during aTSA led to more accurate glenoid component version correction and similarly accurate inclination correction. Additional research should examine the influence of proper component position and use of PSI on clinical outcomes.

Carcinogenic, non-carcinogenic risk, and attributable cases to organochlorine pesticide exposure in women from Northern Mexico.

This study aimed to estimate the carcinogenic and non-carcinogenic risk as well as the attributable cases due to exposure to organochlorine pesticides (OCPs): hexachlorobenzene (HCB), dichlorophenyltrichloroethane (DDT), hexachlorocyclohexane (HCH), heptachlor, and chlordane. From serum concentrations of pesticides of interest in a sample of 908 women from Northern Mexico, the risk for both cancer and non-cancer health effects was evaluated. The population attributable fraction (PAF) was also calculated based on summary association estimates between exposure to OCPs and different health events. Findings revealed that due to their OCP exposure slightly less than half of the women in the sample were at increased risk of developing non-cancerous diseases. Moreover, approximately 25% and 75% of participants were at risk of develop some type of cancer associated with their HCB and DDE concentrations, respectively. In addition, it was estimated that 40.5% of type 2 diabetes, 18.7% of endometriosis, and 23.1% of non-Hodgkin's lymphoma cases could have been prevented if women had not been exposed to these OCPs. Results suggest that the use of OCPs may have contributed to the disease burden in the study area and, based on the time required for these substances to be eliminated from the body, there are probably some women who are still at elevated risk of developing diseases associated to OCPs.

Effective interactions, structure, and pressure in charge-stabilized colloidal suspensions: Critical assessment of charge renormalization methods.

Charge-stabilized colloidal suspensions display a rich variety of microstructural and thermodynamic properties, which are determined by electro-steric interactions between all ionic species. The large size asymmetry between molecular-scale microions and colloidal macroions allows the microion degrees of freedom to be integrated out, leading to an effective one-component model of microion-dressed colloidal quasi-particles. For highly charged colloids with strong macroion-microion correlations, nonlinear effects can be incorporated into effective interactions by means of charge renormalization methods. Here, we compare and partially extend several practical mean-field methods of calculating renormalized colloidal interaction parameters, including effective charges and screening constants, as functions of concentration and ionic strength. Within the one-component description, we compute structural and thermodynamic properties from the effective interactions and assess the accuracy of the different methods by comparing predictions with elaborate primitive-model simulations [P. Linse, J. Chem. Phys. 113, 4359 (2000)]. We also compare various prescriptions for the osmotic pressure of suspensions in Donnan equilibrium with a salt ion reservoir and analyze instances where the macroion effective charge becomes larger than the bare one. The methods assessed include single-center cell, jellium, and multi-center mean-field theories. The strengths and weaknesses of the various methods are critically assessed, with the aim of guiding optimal and accurate implementations.

Higher Upper Subscapularis Goutallier Grade and Coracohumeral Distance Narrowing Are Predictive of Subscapularis Tears in Patients Undergoing Arthroscopic Rotator Cuff Repair.

PURPOSE: To evaluate the relation between subscapularis (SSC) Goutallier grade or coracohumeral distance (CHD) and SSC tears, as well as the relation between these radiographic variables and long head of the biceps tendon lesions. METHODS: A retrospective analysis was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair of SSC tears between 2011 and 2021 with at least 6 months of follow-up. Patients with identified subscapularis tears during arthroscopy were included. A control group was established by randomly selecting patients without SSC tears from the same study period. Goutallier grading and CHD were obtained from preoperative magnetic resonance imaging (MRI) scans. Receiver operating characteristic analysis was conducted to define optimal cutoff values for these diagnostic measures. RESULTS: The study included 735 patients with SSC tears and 249 patients in the control group. Comparing subscapularis tear and intact groups' Goutallier grades revealed significant differences in infraspinatus, upper and lower SSC, and overall SSC (P < .001). No significant difference was detected in supraspinatus Goutallier grade (P = .364). An SSC tear was observed in 58.3% (n = 265) of patients with Goutallier grade 0 of the upper SSC, 77.1% (n = 195) of patients with grade 1 changes, 98.7% (n = 155) with grade 2 changes, and 100% of grade 3 or 4 changes. Goutallier grade of the upper SSC showed a significant correlation with tear size (rs = 0.533; P < .01). CHD measurements were lower in individuals with SSC tears compared to those without tears (6.6 ± 1.7 vs 9.6 ± 1.8; P < .001). Upper SSC Goutallier grade >1 had an acceptable area under the curve (AUC) of 0.742. CHD of 7.96 mm or less had an excellent predictive AUC of 0.879. CONCLUSIONS: Higher Goutallier grade and CHD narrowing are potential associations predictive of SSC tears. Routine MRI assessment of muscle of the upper SSC and the CHD can contribute to the diagnostic accuracy of SSC tears and offer valuable information regarding the severity of such tears. LEVEL OF EVIDENCE: Level III, diagnostic study.

Rip-Stop Fixation Constructs for Rotator Cuff Repair.

In arthroscopic rotator cuff repair, poor tendon quality, medially based tears, lateral tendon loss, or limited tendon mobility can all preclude the use of double-row suture constructs, presenting a challenge in achieving secure fixation and tendon-to-bone healing. Rip-stop suture configurations can be used in these settings to improve resistance to tissue cutout and provide enhanced biomechanical characteristics compared with standard single-row repairs. The load-sharing rip-stop technique uses 2 double-loaded medial suture anchors, which are placed adjacent to the articular margin, and 1 rip-stop suture tape, which is independently secured to bone with 2 lateral knotless anchors. The load-sharing rip-stop technique has been shown to improve ultimate load to failure by 1.7 times compared with a single-row repair. Clinically, this technique has been associated with a 53% healing rate of large and massive rotator cuff tears, compared with only 11% healing when using single-row repair. A completely knotless variation rip-stop configuration also has been described and shown to be biomechanically equivalent to a single-row repair with triple-loaded anchors. For surgeons desiring a single-row repair only, the knotless rip-stop therefore presents an advantage by eliminating the need for knot-tying and decreasing operative time.

The Majority of Sports Medicine and Arthroscopy-Related Randomized Controlled Trials Reporting Nonsignificant Results Are Statistically Fragile.

PURPOSE: To evaluate the robustness of sports medicine and arthroscopy related randomized controlled trials (RCTs) reporting nonsignificant results by calculating the reverse fragility index (RFI) and reverse fragility quotient (RFQ). METHODS: All sports medicine and arthroscopic-related RCTs from January 1, 2010, through August 3, 2021, were identified. Randomized-controlled trials comparing dichotomous variables with a reported P value ≥ .05 were included. Study characteristics, such as publication year and sample size, as well as loss to follow-up and number of outcome events were recorded. The RFI at a threshold of P < .05 and respective RFQ were calculated for each study. Coefficients of determination were calculated to determine the relationships between RFI and the number of outcome events, sample size, and number of patients lost to follow-up. The number of RCTs in which the loss to follow-up was greater than the RFI was determined. RESULTS: Fifty-four studies and 4,638 patients were included in this analysis. The mean sample size and loss to follow-up were 85.9 patients and 12.5 patients, respectively. The mean RFI was 3.7, signifying that a change of 3.7 events in one arm was needed to flip the results of the study from non-significant to significant (P < .05). Of the 54 studies investigated, 33 (61%) had a loss to follow-up greater than their calculated RFI. The mean RFQ was 0.05. A significant correlation between RFI with sample size (R2 = 0.10, P = .02) and the total number of observed events (R2 = 0.13, P < .01) was found. No significant correlation existed between RFI and loss to follow-up in the lesser arm (R2 = 0.01, P = .41). CONCLUSIONS: The RFI and RFQ are statistical tools that allow the fragility of studies reporting nonsignificant results to be appraised. Using this methodology, we found that the majority of sports medicine and arthroscopy-related RCTs reporting nonsignificant results are fragile. CLINICAL RELEVANCE: RFI and RFQ serve as tools that can be used to assess the validity of RCT results and provide additional context for appropriate conclusions.

Patients With Functional Somatic Syndromes-Fibromyalgia, Irritable Bowel Syndrome, Chronic Headaches, and Chronic Low Back Pain-Have Lower Outcomes and Higher Opioid Usage and Cost After Shoulder and Elbow Surgery.

PURPOSE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery. METHODS: A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs. RESULTS: The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs. CONCLUSIONS: Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline. LEVEL OF EVIDENCE: Level III, systematic review of Level II-III studies.

Shoulder Arthroplasty Management in the Young Patient With Posterior Glenoid Erosion.

Osteoarthritic shoulders with posterior glenoid erosion present a unique challenge to shoulder arthroplasty surgeons. Although numerous treatment options and techniques have been described, a consensus regarding the optimal surgical management strategy has not been reached. It is important to summarize the best available evidence regarding these different treatment options, with a particular focus on the young patient.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

PURPOSE: The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. METHODS: A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. RESULTS: Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. CONCLUSION: The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. LEVEL OF EVIDENCE: Level I.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability.

BACKGROUND: Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice. METHODS: A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice. RESULTS: All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss. CONCLUSIONS: Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty.

BACKGROUND: The optimal management of primary glenohumeral arthritis (GHOA) in the elderly is an ongoing topic of debate. The purpose of this study was to compare functional outcomes and complications in patients aged 75 years or older treated with anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) for primary GHOA with an intact rotator cuff. METHODS: A retrospective study was performed on a prospectively maintained database which was queried for patients 75 years of age or older who underwent TSA or RSA for primary GHOA with an intact rotator cuff at a single institution between 2012 and 2021 with minimum 2-year follow-up. Patient-reported outcomes (PROs), including Visual Analog Scale for pain, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected preoperatively and postoperatively. Complications, reoperations, and satisfaction were also recorded. The percentage of patients achieving clinically significant improvement was evaluated with the minimally clinical important difference, substantial clinical benefit, and patient acceptable symptomatic state for each PRO. RESULTS: One-hundred and 4 patients were available for analysis, including 67 TSA patients and 37 RSAs with a mean follow-up of 39.4 months. Preoperative baseline characteristics, PROs, and range of motion were similar between groups. RSA was more commonly performed for eccentric glenoid wear (Walch B2/B3, 62% vs. 22%; P < .001). While clinical outcomes improved comparably in both groups, the TSA cohort showed significantly greater improvement in external rotation (36° vs. 26°; P = .013). Both cohorts had low revision (3% for TSA vs. 0% for RSA) and complication (7% for TSA vs. 5% for RSA; P = .677) rates. Satisfaction was similar in both groups (93% for TSA vs. 92% for RSA; P = .900). Clinically significant improvement was comparable between groups based on the American Shoulder and Elbow Surgeons score (minimally clinical important difference, 93% for TSA vs. 100% for RSA; substantial clinical benefit, 82% vs. 95%; patient acceptable symptomatic state, 67% vs. 78%; P > .05). CONCLUSION: In this retrospective small sample size comparison study, TSA and RSA provide similar short-term clinical outcomes for patients 75 years and older with primary GHOA and an intact rotator cuff. Complication and revision rates are comparably low at short-term follow-up. Our data suggests that advanced age alone should not be used as a decision-making tool for TSA vs. RSA in the setting of primary GHOA with an intact rotator cuff.

Perioperative risk stratification tools for shoulder arthroplasty: a systematic review.

BACKGROUND: Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models. METHODS: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated. RESULTS: Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race. CONCLUSION: The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.