Adherence of Patients to Methods of Self-Reduction of Shoulder Dislocation Taught via Smartphones: A Medium-Term Follow-up Survey.

INTRODUCTION: Self-reduction of a shoulder dislocation may reduce the time from injury to reduction and to the relief of patient discomfort. The purpose of this study was to assess adherence to earlier acquired self-reduction techniques during real-time recurrent shoulder dislocation. METHODS: A telephone survey was conducted among 58 patients previously taught shoulder self-reduction via an instructional video sent to their smartphones during a visit to the emergency department (ED) for the treatment of anterior shoulder dislocation. Participants were queried on recurrent dislocations, use of self-reduction methods, success rate, the effect that instruction in self-reduction had on their willingness to participate in recreational sports activities, on the decision to avoid surgery, and on the overall level of satisfaction with self-reduction methods. RESULTS: Forty-five patients (77.6%; average age 31.4±11.7 y, 10 females) were available for follow-up at an average 60.8±11.0 mo after the index visit to the ED. Eighteen of 23 patients (78.2%) who experienced a recurrent dislocation during the follow-up period attempted self-reduction, and 12 of them successfully achieved self-reduction. Sixteen patients (35.6%) reported that the knowledge in self-reduction increased their willingness to participate in recreational sports activities, whereas 4 (8.9%) patients reported that knowledge in self-reduction affected their decision not to undergo surgical stabilization. CONCLUSIONS: Individuals who sustain recurrent shoulder dislocations should be educated on shoulder self-reduction with the aims of minimizing discomfort, obviating referral to the ED, and motivating participation in recreational activities.

The supine moving apprehension test-Reliability and validity among healthy individuals and patients with anterior shoulder instability.

Background: Performance-based tests for patients with anterior shoulder dislocation are lacking. This study determined the reliability and validity of the supine moving apprehension test designed to assess the ability to control anterior instability loads. Methods: Thirty-six participants were recruited (18 healthy individuals, and 18 patients following anterior shoulder dislocation). Healthy participants performed the supine moving apprehension test on 2 separate occasions to determine test-retest reliability. Patients completed the supine moving apprehension test and the Western Ontario Shoulder Instability index before and 6 months after surgical stabilization of their shoulder. The presence of anterior apprehension was also documented post-operatively. Results: The supine moving apprehension test demonstrated good test-retest reliability (intraclass correlation coefficient = 0.74-0.84). Patients performed 18-30 repetitions less than healthy individuals during the supine moving apprehension test (P < 0.01). A strong correlation was found between supine moving apprehension test scores and Western Ontario Shoulder Instability post-operatively (r = -0.74, P ≤ 0.01). Supine moving apprehension test scores significantly improved among patients following surgery (P < 0.01). Patients with a negative apprehension test post-operatively performed the supine moving apprehension test significantly better than patients with a positive apprehension test (P < 0.01). Conclusions: The supine moving apprehension test is reliable and valid among patients with anterior shoulder dislocation and may serve to assess patients' ability to control shoulder anterior instability loads.

Arthroscopic rotator cuff repair in fibromyalgia patients had comparable outcomes to a matched control group.

BACKGROUND: Although fibromyalgia is associated with poor outcomes following orthopedic surgeries, several studies show some benefit from surgical intervention and nevertheless recommend operative treatment when indicated. There is sparse evidence of the effect of fibromyalgia on the outcomes of shoulder surgery. The purpose of this study was to investigate the effect of fibromyalgia on patient-reported outcomes of arthroscopic rotator cuff repair (ARCR). METHODS: All patients with a confirmed diagnosis of fibromyalgia who underwent ARCR in one institution between 2010 and 2021 were included. Data retrieved from medical records included demographics, characteristics of the cuff tear and the surgical procedure, and preoperative and last follow-up (minimum 1 year) postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score, Subjective Shoulder score (SSV), and Numeric Pain Rating Scale (NPRS). A matched controlled group of patients without fibromyalgia who had undergone ARCR was selected according to age, sex, and preoperative DASH, SSV, and NPRS scores. RESULTS: There were no significant differences in demographics, cuff tear and surgical procedure characteristics, and preoperative scores between the fibromyalgia and control groups. The fibromyalgia patients' postoperative scores for all 3 measurements showed significant improvement: SSV by 32.1 (P = 0.004), DASH by 20.3 (P = 0.016), and NPRS by 2.33 (P = 0.017). There were no significant differences in the postoperative DASH, SSV, and NPRS between the fibromyalgia and control groups. CONCLUSION: Fibromyalgia patients with rotator cuff tears who undergo ARCR do not have inferior patient-reported outcomes compared with non-fibromyalgia controls. Fibromyalgia should not be a considered a contraindication for ARCR. LEVEL OF EVIDENCE: III.

Development of a New Model of Humeral Hemiarthroplasty in Rats.

PURPOSE: In vivo models are anatomically comparable to humans allowing to reproduce the patterns and progression of the disease and giving the opportunity to study the symptoms and responses to new treatments and materials. This study aimed to establish a valid and cost-effective in vivo rat model to assess the effects of implanted shoulder hemiarthroplasty materials on glenoid articular cartilage wear. METHODS: Eight adult male Wistar rats underwent right shoulder hemi-arthroplasty. A stainless steel metal bearing was used as a shoulder joint prosthesis. X-rays were performed one week after surgery to verify correct implant position. Additional X-rays were performed 30 and 60 days post-implantation. Animals were sacrificed 24 weeks after implantation. All specimens were evaluated with micro-CT for cartilage and bone wear characteristics as well as histologically for signs of osteoarthritis. Samples were compared to the non-operated shoulders. RESULTS: All animals recovered and resumed normal cage activity. All X-rays demonstrated correct implant positioning except for one in which the implant was displaced. Histologic evaluation demonstrated arthritic changes in the implanted shoulder. Decreased Trabecular thickness and Trabecular Spacing were documented among the implanted parties (p < .05). Bone Mineral Density and Tissue Mineral Density were reduced in the operated shoulder although not significantly (p = .07). CONCLUSIONS: This study demonstrated significant glenoid cartilage wearing in the operated shoulder. Furthermore, the presence of an intra-articular hemiarthroplasty implant diminished underlying glenoid bone quality. This novel, in vivo-model will enable researchers to test implant materials and their effects on cartilage and bone tissue in a cost-effective reproducible rat model.

Combined Bankart and SLAP repair: patient-reported outcome measurements after a minimum 5-year follow-up.

BACKGROUND: Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP). METHODS: Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5 years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well. RESULTS: A total of 150 patients (88% males) with a mean age 23.7 years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8 years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63). CONCLUSION: Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up. LEVEL OF EVIDENCE: III.

Trans tibial amputation with or without a tourniquet in patients with diabetic foot infection and peripheral vascular disease: Comparison of postoperative outcomes.

Background: Transtibial amputation (TTA) due to complications of diabetic foot infection (DFI) or peripheral vascular disease (PVD) is a high-risk procedure in fragile patients. The risks of reoperation, blood loss requiring blood transfusion, and mortality are high. The use of a tourniquet in this procedure is controversial and scarcely reported. Objective: this study aimed to compare the outcomes of TTAs with or without a tourniquet in a single tertiary medical center. Methods: We retrospectively identified all patients who had undergone TTA in our institution (1/2019-1/2020) and included only those who underwent the procedure due to complications of DFI or PVD (n = 69). The retrieved data included demographics, comorbidities, ASA score, the use of a tourniquet, operation duration, pre- and postoperative hemoglobin levels, administration of blood transfusions, hospitalization length, surgical site infection and 60-days reoperation and mortality rates. Results: TTA with a tourniquet was superior to TTA without a tourniquet in reducing the average operation length by 11 min (p = 0.05), the median postoperative hospitalization by 6 days (p = 0.04), and the use of blood transfusions (odds ratio [OR] = 0.176, 95% confidence interval [CI]: 0.031-0.996). Conclusions: Our findings demonstrated advantages in operative time, hospitalization length, and blood transfusion requirement for TTA with a tourniquet compared to TTA without a tourniquet.

Editor's Choice - Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis.

OBJECTIVE: A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents. DATA SOURCES: The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion. REVIEW METHODS: The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I2. RESULTS: In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature. CONCLUSION: This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.

Biodegradable balloon spacer for massive irreparable rotator cuff tears is associated with improved functional outcomes, low revisions, and complications rate at minimum one year follow-up.

PURPOSE: This study was designed to investigate the efficacy of the InSpace balloon spacer with a specific focus on clinical and patient-related parameters, functional scores InSpace durability, and satisfaction in patients with massive irreparable rotator cuff tears (IRCT) at minimum one year follow-up. METHODS: Between 2010 and 2018, patients with symptomatic IRCTs were treated with InSpace balloon implantation. Demographic characteristics, concomitant procedures, and patient's reported outcomes (PROMs) were obtained as well as satisfaction rate and willingness to undergo the procedure again. Need for subsequent surgery and conversion to reverse total shoulder arthroplasty (RTSA) and time to conversion were also evaluated. RESULTS: Seventy-eight patients (mean age of 70 years, range 46-86) who underwent an InSpace (OrthoSpace, Inc., Caesarea, Israel) balloon implantation were included. Mean follow-up was 56 months (median = 49.6, range 16-129 months). Sixteen out of our 29 pseudoparalytic patients (55.2%) exceed 90° of forward flexion post-surgery with mean improvement of 73° (20-150). Patients older than 65 years of age displayed a statistically significant improved ASES score (60.6 to 46.4, P < 0.05). Patients who underwent a subscapularis (SSC) repair demonstrated a superior ASES score (63.4 compared to 50.4, P = 0.06). CONCLUSIONS: Based on the current study, spacer implantation is a low-risk, clinically effective treatment for the patients with IRCTs. Patient-specific parameters such as age, BMI, and gender should be considered during patient selection process. SSC tendon tears should be repaired if needed. Improvement in function and symptoms from this procedure may negate or delay the need for RTSA even for some of the pseudoparalytic patients.

Shoulder assessment by smartphone: a valid alternative for times of social distancing.

BACKGROUND: The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders. METHODS: Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed. RESULTS: Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69-0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22-0.63), and 74.5% and 0.49 (0.25-0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner. CONCLUSIONS: Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesions: Outcomes at 2-Year Follow-up.

BACKGROUND: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. PURPOSE: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. RESULTS: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. CONCLUSION: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Effects of focused continuous pulsed electromagnetic field therapy on early tendon-to-bone healing.

AIMS: Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. METHODS: A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals' left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. RESULTS: Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. CONCLUSION: MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298-306.

Self-reduction techniques taught via smartphone are effective for anterior shoulder dislocation: prospective randomized study.

PURPOSE: To prospectively compare the effectiveness of three methods for self-assisted shoulder reduction demonstrated using a smartphone video link. BACKGROUND: Anterior shoulder dislocation is very common among young adults. Patients often seek medical assistance in the emergency department to reduce their shoulder. Many techniques for shoulder reduction had been described, some of which do not require professional assistance and can be performed by patients themselves. METHODS: Patients admitted with anterior shoulder dislocation were randomized to either the Stimson, Milch or the Boss-Holtzach-Matter technique. Each patient was given a link to watch a short instructional video on his smartphone and instructed to attempt self-reduction. Success of the reduction, pain level, patient satisfaction and complications were recorded. RESULTS: The study cohort consisted of 58 patients (mean age was 31.6 (18-66, median = 27), 82% males, 88% right hand dominant). Success rate using Boss-Holtzach-Matter (10 of 19, 53%) and self-assisted Milch (11 of 20, 55%) were significantly higher than with the self-assisted Stimson method (3 of 19, 16%), p < 0.05. Pain levels improved from 8.4 (2-10) to 3.1 (0-10) following the reduction. Patient subjective satisfaction from the reduction attempt was 6.7 (0-10). No complications were observed. CONCLUSION:  Both the Self-assisted Milch and the Boss-Holtzach-Matter techniques are ideal for reduction of anterior shoulder dislocation without medical assistance. Both methods can be successfully performed without assistance or previous education and taught using an instructional video. LEVEL OF EVIDENCE: Level II.

Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients?

INTRODUCTION: Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA. MATERIALS AND METHODS: This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS: Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups). CONCLUSION: Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.

Shoulder pain and scapular dyskinesis associated with lower trapezius dysplasia - A case report.

BACKGROUND: Scapular dyskinesis (SD) has been associated with shoulder soft-tissue tightness as well scapular muscle strength and/or activation deficits. Inadequate development of the trapezius muscle (trapezius dysplasia) is a relatively rare condition inconsistently associated with shoulder dysfunction. CASE DESCRIPTION: a 24-year old male complaining of left scapular area pain associated with SD and scapular muscle weakness was noted to present with a smaller ipsilateral lower trapezius (LT). Further inquiry including electromyography, rehabilitative ultrasound imaging (RUSI) and magnetic resonance imaging ruled out nerve palsy and demonstrated a hypoplastic left LT. This led to a greater emphasis on serratus anterior (SA) training along with the addition of neuromuscular electrical stimulation of the LT. OUTCOMES: Following 12 sessions over a 5-month period the patient reported no pain or functional deficits, and was able to resume all recreational activities. The patient's subjective shoulder value increased from 55% to 80%, and LT strength was markedly improved. DISCUSSION: Scapular muscle dysplasia may represent a less recognized cause of SD. A more thorough inspection of scapular muscle shape and orientation, possibly augmented by RUSI may be indicated in patients presenting with SD. Neuromuscular electrical stimulation is a potentially useful modality for addressing scapular muscle activation and strength deficits and future research into its efficacy under these circumstances may be warranted.

Biomechanical evaluation of suture buttons versus cortical screws in the Latarjet-Bristow procedure: a fresh-frozen cadavers study.

INTRODUCTION: A commonly used method of fixation of the transferred coracoid in the traditional Latarjet-Bristow procedure (open or arthroscopic) is by two bicortical screws. Although mechanically effective, screw fixation is also a major source of hardware and neurologic complications. This study aimed to compare the biomechanical performances of traditional metal screws and endobuttons as fixators of the Latarjet-Bristow procedure. MATERIALS AND METHODS: Nine fresh-frozen cadaveric human scapulae with the conjoined tendon attached to the coracoid process were used for the Latarjet-Bristow procedure. The specimens were randomly assigned one of two groups: fixation using two 4.5-mm cannulated partially threaded Latarjet-Bristow experience screws or fixation using a suture-button construct. Specimens were secured in a material testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for ten cycles. They were then pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The maximal load-to-failure, stiffness and stress were calculated using a custom script. The failure mechanism and site were recorded for each specimen. RESULTS: There were no significant differences in the maximal load-to-failure or other biomechanical properties of the two fixation techniques, but the failure mechanisms were unique to each one. Four specimens fixated with screws underwent graft failures (fracture) through the proximal or distal drill hole. Five specimens fixated with endobuttons underwent failure due to glenoid bone fractures. CONCLUSIONS: A single endobutton fixation appears to be biomechanically comparable to screw fixation in the Latarjet-Bristow procedure and provides a lower risk for graft fracture. Further studies with more numerous specimens are warranted to conclusively validate these findings.

Trends in Shoulder Arthroplasty in Israel.

BACKGROUND: The number of patients undergoing shoulder arthroplasty is increasing yearly. OBJECTIVES: To evaluate the results of a consecutive series of patients who underwent shoulder replacement for a variety of indications in a single medical center in Israel. METHODS: All shoulder arthroplasties performed in our institution between 2006 and 2015 were retrospectively reviewed. The functional outcomes and satisfaction of 180 shoulder arthroplasties were evaluated for objective and subjective parameters using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, and the Short Form Health Survey (SF-12). RESULTS: The indications for surgery were osteoarthritis (n=35), rotator cuff arthropathy (n=32), fractures (n=99), and other reasons (n=14). The mean follow-up was 52 months. The scores improved markedly among the patients who underwent surgery later in the study period. The mean DASH score before 2012 was 48.8 and improved to 37.2 after 2013. The respective ASES also improved from 54.2 to 68.6. The use of hemiarthroplasty decreased from 85% to 33% as of 2013, while the use of total shoulder arthroplasty increased. CONCLUSIONS: Shoulder arthroplasty represents an effective treatment modality with satisfactory functional outcomes. Our current study demonstrates a shift from hemiarthroplasty to total shoulder arthroplasty, with the number of procedures increasing yearly. Surgeon experience and the expanding volume of operations had a direct positive effect on the functional outcomes of shoulder arthroplasties.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions.

PURPOSE: This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision. METHODS: ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months. RESULTS: Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm2 vs 48 ± 28 cm2, P = non-significant). CONCLUSION: Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications.

INTRODUCTION: Direct oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral. MATERIALS AND METHODS: This is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients. RESULTS: Patients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015). CONCLUSIONS: DOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

A Simple and Low-cost Drilling Simulator for Training Plunging Distance Among Orthopedic Surgery Residents.

OBJECTIVE: Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth. DESIGN, SETTING, PARTICIPANTS: This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session. RESULTS: Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents. CONCLUSIONS: This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Regulatory Measures Expedited Hip Fracture Surgery Without Lowering Overall Patient Mortality.

OBJECTIVES: Previous observational research has shown that elderly patients with hip fractures who are operated early (within 48 hours from admission) benefit from less short- and long-term mortality compared to those operated later. The objective of this study was to present regulatory measures aimed at promotion of early hip fracture surgery and their effect on the rates of early surgery and on postoperative mortality. DESIGN: Retrospective cohort. SETTING: Single inner-city medical center. PARTICIPANTS: Elderly patients with hip fractures operated during three time periods: 2006 to 2009 (n = 1735, no intervention), 2010 to 2013 (n = 2104, first intervention, positive reinforcement), and 2014 to 2016 (n = 1538, second intervention, positive and negative reinforcement). INTERVENTION: Two regulatory measures were introduced consecutively: staff extra wages for afternoon operations (positive reinforcement) in 2010 and making early operation rates publicly available as the Ministry of Health Quality Care Indexes (negative reinforcement) in 2013. MEASUREMENTS: Percentage of early surgeries and mortality at 1 month and 1 year postoperatively. RESULTS: A total of 5377 patients (1595 men, 3782 women; mean age, 83.1 ± 7.2 years) underwent hip surgery between 2006 and 2016. The three study groups did not differ significantly in age on admission, sex, type of hip fracture (intracapsular or extracapsular), American Society of Anesthesiologists' score, mean hemoglobin on admission, and mean socioeconomic status. The percentage of operations performed within 48 hours was 55%, 65%, and 85%, respectively (P < .001). One-month mortality was 3.9%, 5.1%, and 5%, respectively (P > .05), and one-year mortality was 19.2%, 18.7%, and 19.6%, respectively (P > .05). CONCLUSIONS: Management pressure on the staff to expedite hip surgery and avoid negative publicity in conjunction with additional wages for afternoon surgeries was successful at promoting earlier hip surgery. Despite the substantial increase in the rates of early surgery, however, mortality rates were not affected. J Am Geriatr Soc 67:777-783, 2019.