Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players.

BACKGROUND AND HYPOTHESIS: A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique. MATERIALS AND METHODS: Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score. RESULTS: Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05). CONCLUSION: RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis.

BACKGROUND: Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course than patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with diabetes mellitus and AC without diabetes mellitus. METHODS: Shoulder capsule samples were prospectively obtained from diabetic or nondiabetic patients who presented with shoulder dysfunction and underwent arthroscopy (N = 16). Shoulder samples of AC with and without diabetes (n = 8) were compared with normal shoulder samples with and without diabetes as the control group (n = 8). Shoulder capsule samples were subjected to whole-transcriptome RNA sequencing, and differential expression was analyzed with EdgeR. Only genes with a false discovery rate < 5% were included for further functional enrichment analysis. RESULTS: The sample population had a mean age of 47 years (range, 24-62 years), and the mean hemoglobin A1c level for nondiabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-sequencing analysis revealed that 66 genes were differentially expressed between diabetic patients and nondiabetic patients with AC whereas only 3 genes were differentially expressed when control patients with and without diabetes were compared. Furthermore, 286 genes were differentially expressed in idiopathic AC patients, and 61 genes were differentially expressed in diabetic AC patients. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle-related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin-releasing factor. CONCLUSIONS: Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in the disease course and suggest new therapeutic targets that may lead to different treatment paradigms in these 2 subsets.

Risk factors associated with atraumatic posterolateral rotatory instability.

BACKGROUND: Traumatic posterolateral rotatory instability after elbow dislocation or fracture dislocation has been well described. However, few reports cover atraumatic posterolateral rotatory instability as a cause of lateral-sided elbow pain. We assessed the risk factors and epidemiology of atraumatic posterolateral rotatory instability in a case-control study. METHODS: A retrospective review of all patients treated operatively for atraumatic posterolateral rotatory instability during a 6-year period was compared with a group of patients with extensor carpi radialis brevis tendinopathy without instability treated during the same time period. Bivariate and multiple logistic regression statistical analyses were used to investigate the following risk factors: gender, age, hand dominance, diabetes, smoking, body mass index, corticosteroid injection history, and duration of symptoms. Disabilities of the Arm, Shoulder, and Hand and pain scores were obtained preoperatively and postoperatively. RESULTS: Thirteen patients with atraumatic posterolateral rotatory instability were compared with 12 patients with extensor carpi radialis brevis tendinopathy. Multivariate analysis revealed patients with atraumatic posterolateral rotatory instability were more likely to have multiple corticosteroid injections (P = .05) and present with a longer duration of symptoms (P = .03). Postoperative pain scores improved in both groups. CONCLUSIONS: Atraumatic posterolateral rotatory instability should be considered in the differential diagnosis of lateral elbow when patients present with a protracted clinical course. Statistically, posterolateral rotatory instability patients more often present with a history of multiple corticosteroid injections.

Preoperative tendon retraction, not smoking, is a risk factor for failure with continuity after rotator cuff repair.

BACKGROUND: Smoking is a poor prognostic factor for healing after rotator cuff repair and is associated with inferior results. We hypothesized that smokers would have higher recurrent tear rates and more postoperative myotendinous junction (MTJ) retraction in healed repairs than nonsmokers three months postoperatively. METHODS: Rotator cuff repairs (RCRs) were retrospectively reviewed over a 2-year period. Patients underwent magnetic resonance imaging (MRI) within 6 months prior to surgery and again at 3 months postoperatively. Seventy-nine patients were included and stratified by smokers versus nonsmokers. Baseline patient demographics, tear characteristics, and surgical factors were collected. Preoperative and postoperative MRIs were assessed to quantify the MTJ position and to establish the recurrent tear rate. RESULTS: For the total cohort (nonsmokers, n = 56; smokers, n = 23), significant differences in age, race, and traumatic onset of injury existed between groups. There were no significant differences in recurrent tear between smokers (26%) and nonsmokers (27%), but nonsmokers were more satisfied. For patients with healed RCRs (nonsmokers, n = 41; smokers, n = 17), there were significant differences in race. On univariate analysis, nonsmokers had a significantly more lateral MTJ postoperatively (P = 0.05). On multivariable regression analysis, medialized postoperative MTJ position in healed cuffs was driven only by greater preoperative rotator cuff retraction preoperatively. There were no significant differences in MTJ position based on smoking status for patients with healed RCRs. CONCLUSION: Smoking does not appear to be an independent risk factor for postoperative MTJ retraction in healed RCRs, also known as failure in continuity. Preoperative tear size and retraction play the biggest roles in predicting postoperative MTJ position, regardless of smoking status. There are no significant differences in patient-reported outcomes for patients with healed RCRs, but nonsmokers had more satisfaction following RCR in the total cohort. LEVEL OF EVIDENCE: Level III; Retrospective cohort study; Diagnostic study.

Risk Factors for Cerebral Desaturation Events During Shoulder Surgery in the Beach Chair Position.

PURPOSE: The goals of this study were 2-fold: (1) to determine the risk factors for cerebral desaturation events (CDEs) after implementation of a comprehensive surgical and anesthetic protocol consisting of patient risk stratification, maintenance of normotensive anesthesia, and patient positioning in a staged fashion, and (2) to assess for subclinical neurologic decline associated with intraoperative ischemic events through cognitive testing. METHODS: One hundred patients undergoing shoulder surgery in the beach chair position were stratified for risk of CDE based on Framingham stroke criteria, body mass index (BMI), and history of cerebrovascular accidents. Cerebral oxygen saturation was monitored with near-infrared spectroscopy. As per a standardized protocol, mean arterial pressure was maintained between 70 and 90 mm Hg. The head was raised in 2 stages separated by 3 minutes. CDE were defined as >20% drop from baseline or <55% O2 absolute threshold. Patients completed a Mini-Mental State Examination during preoperative examination and at the first postoperative visit. RESULTS: The CDE rate was 4% overall and 4.3% in patients undergoing general anesthesia. Forty-five patients were in the higher risk category, and all CDEs occurred in that group. Patients with a Framingham score ≥ 10 or BMI ≥ 35 who underwent general anesthesia had an increased risk of CDE (P = .04). No significant change was noted in Mini-Mental State Examination scores between pre- and postoperative visits. No correlation was shown between CDE and history of diabetes, smoking, cardiovascular disease, or left ventricular hypertrophy. CONCLUSIONS: Our observed CDE rate was lower than previously reported rates, likely because of risk stratification, staged positioning, and normotensive anesthesia. Framingham score ≥ 10 and BMI ≥ 35 are risk factors for CDE in the beach chair position. LEVEL OF EVIDENCE: Level II, prospective observational study with >80% follow-up.

Ulnar collateral ligament reconstruction in athletes using a cortical button suspension technique.

BACKGROUND: A variety of techniques currently exist for ulnar collateral ligament (UCL) reconstruction in symptomatic overhead athletes, all with the potential complication of fracture about the humeral or ulnar tunnels. Far cortical button fixation is a reproducible, biomechanically attractive option; however, no clinical series has been published on this technique to date. This study reports the clinical outcomes, with minimum 2-year follow-up, of a dual far cortical button suspension technique for UCL reconstruction in athletes. METHODS: A retrospective evaluation was performed of 23 consecutive athletes who underwent UCL reconstruction with the use of ulnar and humeral-sided far cortical button fixation with minimum 2 years of follow-up. Data were collected from electronic medical records and patient telephone calls. The primary outcome was return to sport. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand score, range of motion, and complications. RESULTS: We included 23 athletes with a mean follow-up of 47.2 months (range, 24-81 months). Autograft was used in 22 patients (16 palmaris, 6 gracilis, 1 semitendinosus, and 1 gracilis allograft). Overall, 82.6% (19 of 23) of patients returned to sport. At final follow-up, the average Disabilities of the Arm, Shoulder and Hand score was 3.8, and range of motion averaged 0° to 140°, with 87% (20 of 23) of patients achieving full motion. The visual analog scale score improved from 3.8 preoperatively to 0.2 at the final follow-up (P < .0001). There was 1 reconstruction failure. CONCLUSIONS: The humeral and ulnar far cortical button suspension technique provides a new UCL fixation option with theoretically lower concern for tunnel fracture and with predictable return to sport and good functional outcomes.

Arthroscopic Cortical Button Stabilization of Isolated Acute Neer Type II Fractures of the Distal Clavicle.

Neer type II distal clavicle fractures are inherently unstable. The purpose of this study was to review the outcome of Neer type II distal clavicle fractures arthroscopically treated using a suspensory cortical button technique. Between 2008 and 2012, a total of 17 Neer type IIB fractures were managed operatively at the authors' institution. Functional outcomes were assessed using the pain score, the Disabilities of the Arm, Shoulder and Hand score, the Penn Shoulder Score, and the American Shoulder and Elbow Surgeons score. Radiographic union was also assessed. At a mean of 1 year, the mean pain score was 0.9±1.1, the mean Disabilities of the Arm, Shoulder and Hand score was 10.9±11.1, the mean Penn Shoulder Score was 90.3±7.9, and the mean American Shoulder and Elbow Surgeons score was 90.1±10.1. Radiographic union occurred in 14 patients. An all-arthroscopic surgical fixation of Neer type II distal clavicle fractures using a suspensory cortical button technique can result in a predictable outcome with a low complication rate. [Orthopedics. 2017; 40(6):e1050-e1054.].

The timing of retears after arthroscopic rotator cuff repair.

BACKGROUND: Little is known about the time dependence of the failure rate of surgically repaired rotator cuffs. Retears are significant, as they are common and may lead to less satisfactory outcomes and additional operations. Their timing is critical foundational information for understanding failure mechanisms. However, this remains unclear. Currently, there exist a number of studies that have reported retear rates at specific time points. Combining data from these publications can reveal when cuffs retear, which will help inform expectations and guidelines for progression of activity after surgery. METHODS: PubMed, Medline, and Embase were searched for studies relating to rotator cuff repair. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Data were extracted from those publications that satisfied all requirements, and regression analysis was performed. RESULTS: Thirteen articles were included in the final meta-analysis. Retear rates for medium tears increased for approximately 15 months and leveled off at approximately 20%. Retear rates for large tears progressed steadily for about 12 months and approached an upper limit of approximately 40%. Retear rates for massive tears ranged from 20% to 60%, but the distribution of retear rate over time for these cuff tears is not clear from these data. CONCLUSION: Retear rates for medium and large tears generally increase until at least 10-15 months after surgery, after which they are likely to level off. Retear rates for massive tears are variable and may follow a time course different from that of other tear sizes. Retear rates depend on size of the original tear.

Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average 5-Year Follow-up.

BACKGROUND: Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes. PURPOSE: To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss <20%. All Hill-Sachs lesions were "off track" by an arthroscopic examination and preoperative imaging. At final follow-up, patients underwent a range of motion evaluation and were administered a detailed outcome survey, which included Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores as well as questions regarding sports, employment, physical activities, and dislocation events. RESULTS: A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation (P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision (P = .062). The average loss of external rotation was 5.26° (P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%. CONCLUSION: The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Large Hill-Sachs Lesion: a Comparative Study of Patients Treated with Arthroscopic Bankart Repair with or without Remplissage.

BACKGROUND: There is little comparative long-term clinical data comparing Bankart repair alone to the addition of remplissage. QUESTIONS/PURPOSES: Our purpose was to compare results of patients with significant humeral head lesions and who underwent either isolated arthroscopic Bankart repair or remplissage. METHODS: This is a retrospective cohort study of 14 isolated arthroscopic Bankart and 10 remplissage repairs all with large engaging Hill-Sachs (HS) lesions. Average follow-up was 40.72 months (26.3-51.1) in the Bankart group and 31.55 months (24.1-39.9) in the remplissage group. Surgical failure was defined as a dislocation or subluxation. Groups were matched on handedness, age within 3 years, and HS lesion size. Glenoid bone loss and HS size were measured on MRI. Additionally, WOSI and DASH scores were obtained. RESULTS: The average age at surgery was 26.0 years (17.8-41.1) of the isolated Bankart patient and 24.4 years (16.4-38.3) in the remplissage group. The average HS lesion volume was 310.22 mm(3) in the Bankart group and 283.79 mm(3) in the remplissage group. The failure rate for the Bankart group was 8 out of 14 patients (57.14%). For the remplissage group, the failure rate was 2 out of 10 patients (20.0%). Average WOSI scores were 73.72 in the Bankart group and 79.54 in the remplissage group. For DASH scores, the average Disability/Symptoms Scores were 16.23 for the Bankart group and 12.05 for the remplissage patients. CONCLUSIONS: In comparison to isolated Bankart repair, remplissage was a superior option for recurrent instability patients with large Hill-Sachs lesions as seen by diminished failure rates and improved outcome scores.

Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.

BACKGROUND: Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections. Most reports have found a high rate of P acnes infection after open surgery, particularly shoulder arthroplasty. However, there are limited data regarding P acnes infections after shoulder arthroscopy. MATERIALS AND METHODS: We prospectively collected data on all shoulder arthroscopies performed by the senior author from January 1, 2009, until April 1, 2013. Cultures were taken in all revision shoulder arthroscopy cases performed for pain, stiffness, or weakness. In addition, 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate. RESULTS: A total of 1,591 shoulder arthroscopies were performed during this period, 68 (4.3%) of which were revision procedures performed for pain, stiffness, or weakness. A total of 20 revision arthroscopies (29.4%) had positive culture findings, and 16 (23.5%) were positive for P acnes. In the control group, 1 patient (3.2%) had P acnes growth. CONCLUSIONS: The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness.

Propionibacterium acnes infections in shoulder surgery.

Perioperative shoulder infections involving Propionibacterium acnes can be difficult to identify in a patient who presents with little more than pain and stiffness in the postoperative period. Although indolent in its growth and presentation, infection of the shoulder with P acnes can have devastating effects, including failure of the surgical intervention. This article reviews the importance of a comprehensive physical, radiologic, and laboratory evaluation, and discusses appropriate preventive and treatment strategies for P acnes infections of the shoulder.

Addressing glenoid bone deficiency and asymmetric posterior erosion in shoulder arthroplasty.

Glenoid bone deficiency and eccentric posterior wear are difficult problems faced by shoulder arthroplasty surgeons. Numerous options and techniques exist for addressing these issues. Hemiarthroplasty with concentric glenoid reaming may be a viable alternative in motivated patients in whom glenoid component failure is a concern. Total shoulder arthroplasty has been shown to provide durable pain relief and excellent function in patients, and numerous methods and techniques can assist in addressing bone loss and eccentric wear. However, the ideal amount of version correction in cases of severe retroversion has not yet been established. Asymmetric reaming is a commonly used technique to address glenoid version, but correction of severe retroversion may compromise bone stock and component fixation. Bone grafting is a technically demanding alternative for uncontained defects and has mixed clinical results. Specialized glenoid implants with posterior augmentation have been created to assist the surgeon in correcting glenoid version without compromising bone stock, but clinical data on these implants are still pending. Custom implants or instruments based on each patient's unique glenoid anatomy may hold promise. In elderly, sedentary patients in whom bone stock and soft-tissue balance are concerns, reverse total shoulder arthroplasty may be less technically demanding while still providing satisfactory pain relief and functional improvements.

Anterior cruciate ligament reconstruction in patients aged > 40 years: a case-control study.

PURPOSE: To determine the outcomes of isolated anterior cruciate ligament (ACL) reconstruction in physically active patients aged > 40 years, and to compare these results with those of a younger patient cohort who underwent the same procedure. METHODS: A retrospective review was performed on all patients aged > 40 years who underwent ACL reconstruction between 2000 and 2008. A consecutive series of patients aged ≤ 25 years who underwent the same procedure during this same time period were selected as a control group. Age, sex, graft type, concomitant injuries, complications, and a validated outcome measure (Lysholm Knee Scoring Scale) were assessed at final follow-up. RESULTS: Forty-six patients (average age, 44.9 years; 28 men, 18 women) in the older group were identified and compared with 48 patients (average age, 21 years; 23 men, 25 women) in the younger group, with an average follow-up period of 5.4 and 5.1 years, respectively. There was no statistically significant difference between the groups in terms of associated injuries. The older group had a higher degree of cartilage degeneration (P = 0.0001). Lysholm scores averaged 90.3 in the older cohort compared with 88.7 in the younger cohort, with no statistical difference between groups. CONCLUSION: The older patients had outcomes comparable with the younger patients. Age alone should not exclude ACL-deficient patients from undergoing reconstructive surgery.

Foreign body reaction to acellular dermal matrix allograft in biologic glenoid resurfacing.

BACKGROUND: Biologic glenoid resurfacing is a treatment option for young patients with glenohumeral arthritis. An optimal synthetic graft for glenoid resurfacing should allow repopulation with host cells, be durable enough to tolerate suture fixation and forces across the joint, and present no host inflammatory response. We report two cases of giant cell reaction to GraftJacket(®) after biologic glenoid resurfacing. CASE DESCRIPTION: Two patients who underwent hemiarthroplasty and biologic glenoid resurfacing using GraftJacket(®) had a foreign body giant cell reaction that required revision surgery. Intraoperatively, both patients were observed to have a well-fixed humeral component and a dense, erythematous, synovitic membrane overlying the glenoid. Pathology specimens showed a benign reactive synovium, chronic inflammation, and foreign body giant cell reaction. After débridement and conversion to total shoulder arthroplasty, both patients continued to be pain-free at greater than 1-year followup. LITERATURE REVIEW: Multinucleated giant cell and mononuclear cell responses have been observed in an animal model after use of GraftJacket(®). Although the use of acellular matrix-based scaffold for biologic glenoid resurfacing is not new, the possibility of foreign body reaction as a source of persistent symptoms has not been described. CLINICAL RELEVANCE: Given the lack of data to indicate an advantage to biologic resurfacing of the glenoid over hemiarthroplasty alone, resurfacing should not introduce significant additional surgical complications. We suggest foreign body reaction be considered in the differential diagnosis for a persistently painful shoulder after biologic glenoid resurfacing using an acellular allograft patch.

Triceps tendon reconstruction using ipsilateral palmaris longus autograft in unrecognized chronic tears.

Injury to the distal triceps tendon is uncommon and can be difficult to diagnose, especially when a partial rupture or tear occurs. In situations where an incomplete disruption to the musculotendinous unit occurs, a palpable defect or clear functional loss may not be present. Advanced imaging techniques, such as magnetic resonance imaging or ultrasound, can be used to confirm the diagnosis and define the extent of injury. The treatment of a complete rupture of the distal triceps tendon is repair or reconstruction, whereas the management of a patient with a partial triceps rupture is related to the pain, functional deficit, and expectations of the patient. This article presents 2 patients with chronic, near complete disruptions of the distal triceps tendon. In both patients, surgical reconstruction of the injured tendon was accomplished using ipsilateral palmaris longus autograft. This technique allows the treating surgeon to harvest the graft from the ipsilateral upper extremity. The palmaris autograft is then used to reconstruct the injured portion of the triceps tendon using a Pulvertaft weave technique through the intact triceps tendon and osseous tunnels within the proximal ulna. This technique allows for easy surgical setup and harvest of autograft tendon and provides a structurally sound technique for a tension-free reconstruction of the injured tendon. It also permits early postoperative elbow range of motion, with active elbow extension allowed at 6 weeks. The authors have used this technique successfully in the treatment of chronic partial tears of the distal triceps tendon.

Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care.

BACKGROUND: It is technically difficult to obtain high-quality, postoperative shoulder radiographs immediately after surgery. Further, poor-quality radiographs may be unlikely to change clinical practice or improve patient outcomes. We therefore questioned the value of routine postoperative radiographs after shoulder arthroplasty. QUESTIONS/PURPOSES: We asked whether (1) postanesthesia care unit (PACU) radiographs can reasonably serve as a baseline for future studies; and (2) routine PACU radiographs change clinical care. (3) We also determined the charges associated with routine PACU radiographs and formal radiographic interpretation of these images. METHODS: We retrospectively compared the radiographs of 283 patients who had shoulder arthroplasties (Group 1) who underwent PACU radiographs with those of 241 patients (Group 2) who had their first postoperative radiographs at a later date. Radiographs were compared for quality, ability to serve as a baseline, and their influence on clinical course. Orthopaedic evaluation of each radiograph and the radiographic report were compared and charges were analyzed. RESULTS: All images in Group 1 were single-view radiographs (88% internal rotation), most were underpenetrated (71%); no images changed postoperative management or were considered adequate to serve as a baseline. Group 2 radiographs were multiview radiographs, and 83% were deemed adequate to serve as baseline radiographs. Radiographic interpretation of immediate postoperative radiographs did not change the clinical course or treatment. The charges billed from radiographic evaluation in this study were $64,524 for Group 1. CONCLUSIONS: Routine PACU radiographs, in the absence of a specific indication, may result in poor-quality images. Elimination of these radiographs and radiographic interpretation after shoulder arthroplasty may reduce charges without changing clinical care. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Fixation strategies to prevent screw cut-out and malreduction in proximal humeral fracture fixation.

Fixation of proximal humerus fractures with precontoured, fixed angle devices has improved operative management of these difficult injuries, particularly in patients with osteoporosis. However, recent data has revealed that fixation with these constructs is not without complications, particularly screw cut-out and loss of reduction. Multiple strategies have been developed to decrease the number of complications. We offer a surgical technique combining suture augmentation of the proximal humerus with locked plate fixation utilizing short screws.