Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears.

BACKGROUND: Nonsurgical management of chronic, degenerative rotator cuff tears (RCTs) can be an effective treatment strategy, but there is limited evidence to support conservative treatment of acute, traumatic RCTs. The objective of this study was to assess clinical outcomes and predictors of treatment success in patients with traumatic RCTs who elected for initial nonoperative treatment. METHODS: Patients from a single institution were retrospectively identified using diagnostic codes for traumatic RCTs followed by confirmed initial treatment with ≥2 months of physical therapy. The exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on magnetic resonance imaging. At minimum 2-year follow-up, patients were contacted by telephone to collect interval surgical history and standardized patient-reported outcomes. Physical therapy was considered to have failed in all those who underwent surgical treatment and those with satisfaction ratings of "moderately dissatisfied" or "very dissatisfied." RESULTS: Follow-up outcomes were obtained in 40 of 49 patients (82%), with an average follow-up time of 4.2 years. Of the RCTs, 9 (22%) were small (<1 cm), 22 (54%) were medium (>1 cm to <3 cm), and 9 (22%) were large (>3 cm to <5 cm). Grade I fatty infiltration was seen on 25% of magnetic resonance imaging scans (n = 10). Rotator cuff repair was performed in 18 patients (45%) following an average of 6 months of nonoperative treatment (range, 3-12 months). Nonoperative treatment was determined to have failed in 23 of 40 patients (58%) in total. Conservative management was more likely to fail in patients with multiple tendons torn (P = .014). Tear size and retraction were not significantly different between patients who underwent surgery and those who did not. Patients who underwent surgical management had an 83% satisfaction rate at final follow-up compared with a 55% satisfaction rate for patients who did not undergo surgery (P = .054). There was no statistically significant difference in the American Shoulder and Elbow Surgeons score or visual analog scale score between these groups. Although patients who underwent surgery had a higher mean Single Alpha Numeric Evaluation score (86.3 vs. 75.1, P = .041), this difference was below the previously established minimal clinically important difference. CONCLUSION: Nonoperative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs.

Work-related outcomes of revision rotator cuff repair for patients receiving workers' compensation.

BACKGROUND: Workers' compensation (WC) patients are susceptible to poorer outcomes following primary rotator cuff repair (RCR). Failure of structural healing can explain some poor results, and outcomes of revision RCR in this population are unknown. METHODS: A retrospective review was performed of individuals receiving WC who underwent arthroscopic revision RCR with or without dermal allograft augmentation at a single institution between January 2010 and April 2021. Preoperative magnetic resonance imaging (MRI) scans were assessed for rotator cuff tear characteristics, Sugaya classification, and Goutallier grade. Postoperative imaging was not routinely obtained unless for continued symptoms or reinjury. Primary outcome measures included return-to-work status, reoperation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) scores. RESULTS: Twenty-seven shoulders (25 patients) were included. The population was 84% male, with a mean age of 54 years; 67% were manual laborers, 11% sedentary workers, and 22% with a mixed profession. Average follow-up was 35.4 months. Fifteen patients (56%) returned to work at full-duty status. Six (22%) returned to work with permanent restrictions. Six (22%) were unable to return to work in any capacity. Thirty percent of all patients and 35% of manual laborers changed occupation following revision RCR. Mean time to return to work was 6.7 months. Overall, symptomatic rotator cuff retear was found in 13 patients (48%). Reoperation rate after revision RCR was 37% (10 cases). Among patients who did not undergo reoperation, mean ASES scores improved from 37.8 to 69.4 at final follow-up (P < .001). Mean SANE scores only improved marginally from 51.6 to 57.0 (P = .61). No statistically significant correlation was found between preoperative MRI findings and outcome measures. CONCLUSION: Workers' compensation patients demonstrated fair improvements in outcome scores after revision RCR. Although some patients are able to return to full duty, nearly half were either unable to return or returned with permanent restrictions. These data are helpful for surgeons when counseling patients about expectations and return to work after revision RCR in this challenging population.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

PURPOSE: The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. METHODS: A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n = 246), 10° superior glenoid augments (n = 97), or combined 10° superior/8° posterior glenoid augments (n = 177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. RESULTS: The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P < .05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P = .006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P < .001), nearly 33% less intraoperative blood loss volume (P < .001), approximately 3-fold less scapular notching (P < .01), and approximately 8-fold less adverse events requiring revision (P < .01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P = .003 and P = .013). CONCLUSION: The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.

Intraoperative Technology Use Improves Accuracy of Functional Safe Zone Targeting in Total Hip Arthroplasty.

BACKGROUND: Targets of acetabular inclination and anteversion have been suggested based on a patient's spinopelvic mobility. Current methods in total hip arthroplasty (THA) include manual instrumentation, computer-assisted navigation, and robotic-assisted surgery. This study aims to compare the accuracy of these 3 methods in targeting the functional safe zone. METHODS: This is a prospective multicenter study including a series of 251 consecutive primary posterior THA patients from April 2019 to January 2021. Preoperative lateral standing and sitting spinopelvic radiographs were obtained. Each patient was classified using the Hip-Spine Classification. A functional safe zone plan was determined. Surgeons used their preferred method (manual instrumentation, computer-assisted, or robotic-assisted). Postoperative anteversion and inclination was measured and compared to the preoperative plan. Mean differences between preoperative and postoperative values were calculated. Welch's t-test was used to assess significant between-group differences with P < .05 considered significant. RESULTS: Of the 249 patients, there were 63 manual instrumentation, 68 computer-assisted navigation, and 118 robotic-assisted surgery. Robotic-assisted surgery (rTHA) was significantly more accurate in targeting anteversion (1 ± 2) compared to manual instrumentation (mTHA; 7 ± 6, P < .001) and computer-assisted navigation (cTHA; 6 ± 6, P < .001). rTHA was also significantly more accurate in targeting inclination (1 ± 1) compared to mTHA (8 ± 7, P < .001) and cTHA (6 ± 7, P < .001). Although cTHA had greater accuracy in targeting both inclination and anteversion compared to mTHA, these differences were not statistically significant. CONCLUSION: Robotic-assisted surgery was more accurate than both computer-assisted navigation and manual instrumentation in targeting the functional safe zone in primary THA. Further research is needed to evaluate the effect of improved accuracy on dislocation rates.

Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications?

BACKGROUND: The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS: A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS: In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION: Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in idiopathic adhesive capsulitis.

PURPOSE: To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with pre-existing validated outcome scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC). METHODS: Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcome scores were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were calculated. RESULTS: The final cohort included 100 patients with AC, of whom there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ± 1.84) compared with the fixed question burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed an excellent correlation with both the ASES (r = 0.80, 95% confidence interval [0.72, 0.86], P < .001) and CS (r = 0.76, 95% confidence interval [0.67, 0.83], P < .001). Neither ceiling nor floor effects were present. CONCLUSION: The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in AC. A lower question burden with the PROMIS UE carries potential for wider acceptability with the researchers and patients with shoulder pathology.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

PURPOSE: The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS: The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS: A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION: Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE: III.

A Preoperative Workup of a "Hip-Spine" Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem.

BACKGROUND: A large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA). METHODS: Achieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position. RESULTS: Based on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the "Hip-Spine Classification in THA." A series of illustrative case examples is provided. CONCLUSION: A simple three-step assessment with minimal measurements will effectively identify the complex "hip-spine" THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty.

BACKGROUND: Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. METHODS: All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. RESULTS: Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. CONCLUSION: GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

The Evolution of Cement Fixation in Total Knee Arthroplasty.

Aseptic loosening and infection are two of the leading causes of revision in total knee arthroplasty. While several patient-related factors can play a role in the development of these complications, there are certain modifiable surgeon factors that can help mitigate the risk. Intraoperatively, this can begin with the curing process of bone cement which is broken down into four different stages: mixing, waiting, working, and setting. Understanding each stage of the process is beneficial in obtaining successful long-term outcomes. Developing optimal bone-cement penetration is of utmost importance in establishing a strong interface. Proper penetration of cement is dependent on multiple factors including the cement's properties along with its application to the prosthesis and bone surfaces. Combinations of different cement application techniques have yielded results with varying bone-cement interface strength. While a proper cementation technique is critical to the long-term success of a total knee replacement, other factors, such as antibiotic-loaded bone cement (ALBC), can help prevent and treat complications (such as infection). Although ALBC was not approved in North America by the Food and Drug Administration (FDA) until 2003, it was first described in 1970 and has been routinely used in revision total knee arthroplasty with reliable antibiotic elution properties and an acceptable safety profile.

Biomechanical Performance of Medial Row Suture Placement Relative to the Musculotendinous Junction in Transosseous Equivalent Suture Bridge Double-Row Rotator Cuff Repair.

PURPOSE: To compare the biomechanical performance of medial row suture placement relative to the musculotendinous junction (MTJ) in a cadaveric transosseous equivalent suture bridge (TOE-SB) double-row (DR) rotator cuff repair (RCR) model. METHODS: A TOE-SB DR technique was used to reattach experimentally created supraspinatus tendon tears in 9 pairs of human cadaveric shoulders. The medial row sutures were passed either near the MTJ (MTJ group) or 10 mm lateral to the MTJ (rotator cuff tendon [RCT] group). After the supraspinatus repair, the specimens underwent cyclic loading and load to failure tests. The localized displacement of the markers affixed to the tendon surface was measured with an optical tracking system. RESULTS: The MTJ group showed a significantly higher (P = .03) medial row failure (5/9; 3 during cyclic testing and 2 during load to failure testing) compared with the RCT group (0/9). The mean number of cycles completed during cyclic testing was lower in the MTJ group (77) compared with the RCT group (100; P = .07) because 3 specimens failed in the MTJ group during cyclic loading. There were no significant differences between the 2 study groups with respect to biomechanical properties during the load to failure testing. CONCLUSIONS: In a cadaveric TOE-SB DR RCR model, medial row sutures through the MTJ results in a significantly higher rate of medial row failure. CLINICAL RELEVANCE: In rotator cuff tears with tendon tissue loss, passage of medial row sutures through the MTJ should be avoided in a TOE-SB RCR technique because of the risk of medial row failure.

Periprosthetic Joint Infection After Hip and Knee Arthroplasty: A Review for Emergency Care Providers.

Periprosthetic joint infection is among the most common modes of failure of a total hip or knee arthroplasty and can be a common concern when patients present to the emergency department for care. The initial evaluation for periprosthetic joint infection includes a history and physical examination, followed by radiographs (to rule out other causes of pain or failure) and then serum erythrocyte sedimentation rate and C-reactive protein testing. If the erythrocyte sedimentation rate and C-reactive protein level are elevated or if the clinical suspicion for infection is high, the joint should be aspirated and the fluid sent for culture, as well as for a synovial WBC count and differential, with optimal threshold values of 3,000 WBC/µL and 80% polymorphonuclear cells, respectively. Recent work has shown that optimal cutoff values for patients presenting in the early postoperative period (within the first 6 weeks postoperatively) are different, with a C-reactive protein level greater than or near 100 mg/L (normal <10 mg/L), indicating the need for aspiration, with synovial fluid WBC thresholds of 10,000 WBC/µL and 90% polymorphonuclear cells. Antibiotics should not be administered before joint aspiration unless the patient has systemic signs of sepsis because even a single dose may cloud the interpretation of subsequent tests, including cultures taken from the joint. Furthermore, superficial cultures taken from wound drainage are discouraged because they can similarly cloud diagnosis and treatment. The rising prevalence of total joint arthroplasty makes proficiency in the assessment and early management of periprosthetic joint infection important for the emergency physician to optimize clinical outcomes.

Stemless Reverse Shoulder Arthroplasty.

Since the Food and Drug Administration (FDA) approval nearly two decades ago, the indications for and utilization of reverse shoulder arthroplasty (RSA) have expanded considerably. Stemless RSA designs have been used in Europe since 2005, but have only recently been introduced in domestic Investigational Device Exemption trials. Potential advantages of stemless RSA are similar to those of stemless anatomic total shoulder arthroplasty, which may include fewer shaft-related complications, avoidance of stress shielding, bone preservation, and easier revision surgery. European data support similar outcomes between certain stemless RSA prostheses compared with that of stemmed RSA implants at early and mid-term follow-up. However, long-term outcomes remain to be seen and differences exist between the stemless RSA designs used in Europe and those being studied in domestic clinical trials. An understanding of the potential advantages and disadvantages of stemless RSA, differences between existing designs, and reported clinical outcomes is prudent for the safe and meaningful implementation of this new technology in the United States.

Pediatric Forearm Muscle Herniation Treated With an Acellular Dermal Allograft.

Muscle herniations occur through acquired fascial defects in the lower extremities; upper-extremity herniations are rare. The affected patients are typically adult men engaging in strenuous exercise or with injury; pediatric cases are infrequent. We a pediatric patient with a symptomatic, forearm herniation treated with fascial defect closure using an acellular dermal allograft. This case report highlights not only the presence of this rare condition in pediatrics but also a safe and viable treatment option for this patient population. The patient presented with pain and soft-tissue swelling of the forearm, was diagnosed with muscular herniation, and was surgically treated with fascial defect closure using an acellular dermal allograft. All symptoms resolved, without the recurrence of herniation and with return to sport. Upper-extremity muscle herniations are rare but should be considered in pediatric patients following trauma/surgery and can be treated successfully with acellular dermal allografts.

An Analysis of Component Positioning, Offset, and Limb Length Restoration in Computer-Assisted Hip Resurfacing Arthroplasty.

INTRODUCTION: Hip resurfacing arthroplasty (HRA) is a surgical option with positive outcomes at medium-term follow-up for young, active patients with osteoarthritis. However, early failures of HRA often occur due to improper implant placement. The purpose of this study was to assess the utility of computer-assisted navigation in the effort to optimize implant positioning following HRA. MATERIALS AND METHODS: A retrospective analysis of 262 consecutive HRAs at a single institution was performed. Radiographic analysis included measurements of cup inclination and anteversion, leg length restoration (LLR), and offset. Cup position was evaluated based on placement within Lewinnek parameters and the surgeon's preferred anteversion (10° to 20°). Chi-squared and unpaired Student's t-test were performed for all categorical and continuous variables, respectively. RESULTS: One hundred fifty-six cases were performed using conventional technique and 106 cases used computernavigation. Computer-assisted HRA (caHRA) had a longer mean surgical time (129 vs. 110 minutes; p < 0.001) but shorter average LOS (1.1 vs. 1.5 days; p < 0.001). Cup position was within the surgeon-preferred target zone in 47% of caHRA versus 22% of conventional HRA (p = 0.0001). Cup position fell within the Lewinnek safe zone in 86% of caHRA versus 60% of conventional HRA (p < 0.001). Global offset was reduced by a mean of 6.4 mm in caHRA versus 8.4 mm (p = 0.036). No differences in rates of complication (p = 0.406), reoperation (p = 1.00), or 90-day readmission (p = 0.568) were observed. CONCLUSION: Computer-assisted technology in HRA allows for comparable clinical outcomes to conventional technique. Cup position accuracy and precision is improved by computer navigation in HRA.

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis.

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Developing a successful robotics program.

PURPOSE OF REVIEW: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to evaluate the important considerations in developing a new robotics program at a given healthcare institution. RECENT FINDINGS: Patients' interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. Given proper surgeon experience and an efficient system, robotic-assisted procedures have been cost comparable to open surgical alternatives. Surgeon training and experience is closely linked to the efficiency of a new robotics program. Formally trained robotic surgeons have better patient outcomes and shorter operative times. Training in robotics has shown no negative impact on patient outcomes or mentor learning curves. SUMMARY: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volume. A mature, experienced surgeon is integral to the success of a new robotics program.

Reverse Total Shoulder Arthroplasty Biomechanical Considerations and the Concept of Lateralization.

The biomechanical concepts underlying total shoulder arthroplasty including differences between the anatomic total and reverse total shoulder arthroplasty (RTSA) are reviewed. The concept of lateralization and its implications on outcomes after RTSA is explained through a historical perspective. Finally, how lateralization can be achieved via different components of an RTSA construct, as well as the potential disadvantages or trade-offs that must be considered when lateralizing in reverse shoulder arthroplasty, are discussed.

Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy (PAO) has been used as a treatment modality for development dysplasia of the hip (DDH). Many patients will progress to total hip arthroplasty (THA) following PAO. There is a discrepancy in the literature regarding outcomes of THA after PAO. METHODS: A retrospective study was performed. Ten pa- tients (12 hips) with prior PAO who progressed to THA with at least 1-year follow-up after THA were identified. A control group of patients matched for age, sex, and body mass index (BMI) who underwent primary THA with minimum of 1-year follow-up were included. Demographic and radiographic parameters as well as clinical outcomes using the modified Harris Hip Score (mHHS) were collected. RESULTS: The mean age at the time of THA was 36.2 ± 9.7 years for the PAO and 37.8 ± 9.1 years for the control cohorts. There was no difference in the demographics be- tween the groups. At mean follow-up time of 22.8 ± 10.7 months for the PAO group and 25 ± 13.8 months for the control group, there was no significant difference in mHHS following THA. There was significant improvement in mHHS from preoperative to postoperative levels (p < 0.01). CONCLUSION: Total hip arthroplasty is an effective means to restore quality of life and function in patients who develop osteoarthritis following PAO, with equivalent outcomes to those undergoing primary THA.