Lateral Femoral Condyle Allograft in the Treatment of Elbow Capitellar Avascular Necrosis: A Case Report.

CASE: A 27-year-old woman developed capitellar osteonecrosis after long-term corticosteroid use to treat non-Hodgkin lymphoma. She underwent an osteochondral reconstruction using a lateral femoral condyle (LFC) allograft. This graft was selected because it has a similar radius of curvature to the capitellum. The patient had osseous integration, painless, near full range of motion of her elbow 6 months postoperatively and good shoulder function 1.0 year postoperatively. CONCLUSION: The LFC allograft should be considered a viable option in treating capitellar osteonecrosis.

Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review.

Solid organ transplants (SOT) have evolved into life-saving interventions for end-stage diseases affecting vital organs. Advances in transplantation techniques, donor selection, and immunosuppressive therapies have enhanced outcomes, leading to a growing demand for SOT. Patients with a solid organ transplant are living long enough to develop the same pathologies which are indicated for joint replacement surgery in the general population. SOT patients who undergo a total hip, knee, or shoulder arthroplasty do similarly in the context of clinical outcomes and implant survival when compared to the general population. These immunosuppressed patients tend to have higher complication rates in the short-term following surgery. Prudent management of these patients in the short-term may be necessary, but patients can expect to do well otherwise.

The role of body mass index in survivorship and clinical outcomes in total shoulder arthroplasty.

BACKGROUND: Increased body mass index (BMI) is a potential risk factor for poorer outcomes and complications. However, the influence of BMI on the long-term outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) remains to be fully elucidated. METHODS: Institutional records were queried to identify patients who underwent primary total shoulder arthroplasty (TSA) between 2009 and 2020 with a minimum of 2 years of clinical follow-up. Retrospective review was performed to collect demographic characteristics; comorbidity status; and range-of-motion and strength measurements in forward elevation, external rotation, and internal rotation. Patients were contacted by telephone to provide patient-reported outcomes (PROs). Patients were stratified into 3 cohorts by BMI: underweight or normal weight (U/NW, BMI ≤25 kg/m2), overweight (OW, BMI >25 to ≤30 kg/m2), and obese (BMI >30 kg/m2). RESULTS: Among 466 TSA patients, 245 underwent aTSA whereas 221 underwent rTSA. In the aTSA cohort, 40 patients were classified as U/NW; 72, as OW; and 133, as obese. Comparatively, the rTSA cohort was composed of 33 U/NW, 79 OW, and 209 obese patients. Patients in the aTSA and rTSA cohorts had an average follow-up period of 5.8 ± 3.2 years and 4.5 ± 2.3 years, respectively. No differences in age at surgery were found in the aTSA group (U/NW vs. obese, 65.2 ± 7.9 years vs. 61.9 ± 8.9 years; P = .133); however, in the rTSA cohort, BMI was found to be inversely related to age at surgery (U/NW vs. obese, 72.4 ± 8.8 years vs. 65.7 ± 8.3 years; P < .001). Across all BMI cohorts, patients saw great improvements in range of motion and strength. Postoperative PROs after TSA did not vary by BMI in terms of Single Assessment Numeric Evaluation, Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons scores. There was no significant difference in survival rates at 10-year follow-up in the aTSA cohort (U/NW vs. obese, 95.8% vs. 93.2%; P = .753) or rTSA cohort (U/NW vs. obese, 94.7% vs. 94.5%; P = .791). CONCLUSION: With dramatic improvements in range of motion, minimal differences in PROs, and high rates of implant survival, TSA is a safe and effective treatment option for all patients, including overweight and obese patients.

Modern Applications of Machine Learning in Shoulder Arthroplasty: A Review.

¼ There is increased integration of machine learning (ML) to aid clinical decision-making in orthopaedic surgery.¼ ML has the ability to predict both clinical outcomes such as range of motion and complications in total shoulder arthroplasty patients.¼ An increased area of focus is the ability for ML to identify implants to aid in revision surgery planning.¼ In this article, we review the current applications of ML in shoulder arthroplasty and discuss future areas where it may enhance orthopaedic practice.

Shoulder arthroplasty following solid organ transplant: A systematic review and meta-analysis.

Introduction: The purpose of this study is to report a systematic review and meta-analysis of solid organ transplant (SOT) patients undergoing shoulder arthroplasty to compare functional and radiographic outcomes, demographics, and complications with non-transplant patients. Methods: Studies were included if they examined patients undergoing shoulder arthroplasty in the setting of prior solid organ transplantation and included post operative range of motion, patient-reported outcomes, complications, or revisions. Studies were excluded if they were national database analyses or lacked clinical data. Pubmed, MEDLine, Scopus, and Web of Science were queried using relevant search terms in July 2022. Data was pooled, weighted, and a paired t-test and chi-square analysis was performed. Results: There were 71 SOT and 159 non-SOT shoulders included in the study. The most common indication for surgery was avascular necrosis (n = 26) in the solid organ transplant group and osteoarthritis (n = 60) in the non-SOT group. Forward elevation, external rotation, ASES, and VAS pain scores improved significantly in both cohorts following surgery. There was no significant difference in age at surgery (p-value = 0.20), postoperative forward elevation (p-value = 0.08), postoperative external rotation (0.84), and postoperative ASES scores (p-value = 0.11) between the two cohorts. VAS pain scores were significantly lower in the SOT cohort (p-value<0.01). The risk of death was significantly higher in the SOT group (p-value<0.01). but the rate of overall complications (p = 0.47), surgical complication (p-value = 0.79), or revision surgery (p-value = 1.00) was not significantly different between the two cohorts. Conclusion: Shoulder arthroplasty is a safe, effective option in patients following solid organ transplant. There is not an increased risk of adverse outcomes, and SOT patients had comparable range of motion and patient-reported outcomes when compared to their non-SOT peers. Level of evidence: III.

The role of the long head of the biceps tendon in posterior shoulder stabilization during forward flexion.

BACKGROUND: The role of the long head of the biceps tendon (LHBT) in glenohumeral stability is not fully understood. Most objects are lifted in the sagittal plane with forward flexion, which stresses the posterior aspect of the unconstrained glenohumeral joint. Determining the mechanism by which the shoulder maintains stability with functional motions is important to understanding the pathoanatomy of degenerative shoulders. Our hypothesis was that the LHBT resists posterior translation of the humeral head (HH) during forward flexion by tensioning the posterior capsuloligamentous complex. METHODS: Ten fresh-frozen cadaveric shoulders were tested using an established shoulder simulator that loads the LHBT, rotator cuff, and deltoid tendons through a system of pulleys. A motion tracking system recorded glenohumeral translations with an accuracy of ±0.2 mm. In each subject, the scapula was fixed and the humerus was tested in 6 positions: 30° and 60° of glenohumeral forward flexion at (1) maximum internal rotation (IR), (2) neutral rotation, and (3) maximum external rotation (ER). The deltoid was loaded with 100 N, and the infraspinatus and subscapularis were loaded with 22 N each. The difference in glenohumeral translation was calculated at each position comparing the LHBT loaded with 45 N or unloaded. RESULTS: At 30° of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.5 mm (±0.9 mm; P < .001), 1.7 mm (±1.0 mm; P < .001), and 1.0 mm (±0.9 mm; P = .01) at maximum ER, neutral rotation, and maximum IR, respectively. At 60° of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.8 mm (±1.2 mm; P < .001), 2.4 mm (±1.6 mm; P < .001), and 1.7 mm (±1.4 mm; P < .001) at maximum ER, neutral rotation, and maximum IR, respectively. CONCLUSION: LHBT loading resists posterior translation of the HH during forward flexion. These data support the role of the LHBT as a posterior stabilizer of the shoulder, specifically when a person is carrying objects in front of them. Further work is needed to determine if unloading the LHBT, as is done with biceps tenotomy or tenodesis, may eventually lead to posterior labral pathology, or to the posterior glenoid wear commonly seen with osteoarthritis.

Decreased Trunk Rotation at Foot Contact in Professional Baseball Pitchers With Prior Conservatively Managed SLAP Tears: A Propensity Score-Matched Analysis.

PURPOSE: To compare kinematic and kinetic parameters between a cohort of fully recovered professional pitchers with prior shoulder injury treated conservatively and a cohort with no prior shoulder injury. METHODS: Twenty-six fully recovered professional baseball pitchers with a history of shoulder injury treated conservatively pitched 8 to 10 fastball pitches using 3-dimensional motion capture (480 Hz). All shoulder injuries occurred within a 1- to 4-year time span from biomechanical evaluation and were severe enough to prevent pitchers from playing for between 1 and 12 months. These pitchers were propensity score matched by age, height, weight, handedness, and ball velocity to pitchers with no prior injury history (control) at a ratio of 1:4. We compared 21 kinematic and 11 kinetic parameters between groups using appropriate parametric testing. Subanalysis comparisons of pitchers with prior SLAP injury as well as rotator cuff tendinitis were also performed. RESULTS: SLAP tears (n = 11, 42.3%) were the most frequently reported injury, followed by rotator cuff tendinitis and/or shoulder impingement (n = 7, 26.9%). Compared with the control group, the 26 pitchers with prior injury showed no significant differences across the kinematic and kinetic factors. However, the SLAP tear subgroup did show significantly less trunk rotation at foot contact compared with controls (34.1° ± 4.9° vs 39.2° ± 10.2°, P = .0075). CONCLUSIONS: Fully recovered professional baseball pitchers with shoulder injuries treated conservatively showed no significant differences in kinetics or kinematics compared with their propensity score-matched counterparts, suggesting that shoulder injury alone may not greatly alter pitching mechanics. However, whereas prior groups have shown a decrease in trunk rotation at foot contact after surgical repair for SLAP tears, our study suggests that this kinematic change may alternatively originate with the injury itself. CLINICAL RELEVANCE: Understanding the cause of biomechanical adaptations by pitchers after injury can better aid clinicians and coaching staff in providing individualized and specific care to the throwing athlete.

Patient-Reported Outcomes and Factors Associated with Achieving the Minimal Clinically Important Difference After ACL Reconstruction: Results at a Mean 7.7-Year Follow-up.

BACKGROUND: Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR. METHODS: Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID. RESULTS: A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p < 0.0001), while the SF-12 MCS did not improve significantly (54.2 ± 8.0 to 54.4 ± 6.0) (p = 0.763). Between 2- and >5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either "very" or "somewhat" satisfied with their surgery, compared with 88.6% at the time of final follow-up. CONCLUSIONS: We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Return to Sport After Bone-Patellar Tendon-Bone Autograft ACL Reconstruction in High School-Aged Athletes.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations. PURPOSE/HYPOTHESIS: To evaluate outcomes after bone-patellar tendon-bone (BTB) autograft ACLR in competitive high school-aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An institutional ACL registry was utilized to identify competitive high school-aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS. RESULTS: A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis. CONCLUSION: BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school-aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.

The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy.

PURPOSE: The purpose of this study is to further evaluate the construct validity and interobserver reliability of a hip arthroscopy virtual simulator using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) global rating scale. METHODS: Thirty participants (23 male/7 female) completed a diagnostic arthroscopy and a loose body retrieval simulation on the VirtaMed Arthros Hip Simulator (Zurich, Switzerland) twice at a minimum of 1 week apart. Subjects consisted of 12 novices (medical students, postgraduate year [PGY] 1-2), 5 intermediate trainees (PGY3-4), 9 senior trainees (PGY5 and fellows), and 4 attending faculty. Simulator metrics were recorded and then compiled to generate a total simulator score (TSS). The loose body retrieval was graded using the ASSET scoring tool. Inter-rater and intrarater reliability for the ASSET for 2 blinded raters and construct validity of the ASSET and the TSS were calculated. Correlation between the TSS, ASSET and individual simulator metrics was determined. RESULTS: Prior simulation experience (P ≤ 0.01) correlated with higher TSS and higher ASSET, while video game experience correlated with higher TSS on the diagnostic module only (P = 0.004). There was a significant difference in ASSET score among all experience groups (P < 0.04). Novices had the lowest mean ASSET whereas experts had the highest mean ASSET with a difference of 17.4 points. Overall performance on the surgical module significantly correlated with the ASSET score (r = 0.444, P = 0.016). There was a significant positive correlation among higher ASSET and number of loose bodies retrieved, operation time, camera path and grasper path length, and percentage of cartilage injury. ASSET demonstrated excellent intrarater reliability and showed substantial or better inter-reliability in 8 of 9 domains. CONCLUSION: The VirtaMed hip arthroscopy simulator demonstrated good construct validity and excellent reliability for simulator-based metrics and ASSET score. Use of both simulator metrics and ASSET offers a more comprehensive performance assessment on hip arthroscopy simulation than either measure alone. CLINICAL RELEVANCE: As virtual reality simulation for arthroscopy becomes more commonplace in orthopaedic training, evaluation of the most effective objective and subjective measures of performance is necessary to optimize simulation training.

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling.

Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge (P=.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m2, American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low pre-operative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty. [Orthopedics. 2021;44(2):e215-e222.].

Survivorship of a Medialized Glenoid and Lateralized Onlay Humerus Reverse Shoulder Arthroplasty Is High at Midterm Follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a common treatment of a variety of disabling shoulder conditions. The purpose of this study was to determine revision-free survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus implant and to identify etiologies of revision. METHODS: All RSAs performed using the Comprehensive® Reverse Shoulder System (Zimmer Biomet, Inc.; Warsaw, IN, USA) at one institution from 2008 to 2014 were identified through a retrospective review. Charts were reviewed to determine whether the RSA was a primary or revision surgery. Patients were contacted by telephone, and survivorship was defined as no subsequent surgery after RSA. Of the 526 RSAs performed, responses were obtained from 403 patients (77%). A Kaplan-Meier analysis was performed to determine survivorship over time. A χ 2 test was used to determine differences between revision rates after RSA. RESULTS: Minimum follow-up was 3 years, and average follow-up was 4.83 ± 1.60 years. Survivorship was 96% at 2 years and 93% at 5 years after RSA. Revisions were performed for instability (n = 8), humeral tray-taper junction failure (n = 5), acute fracture (n = 4), infection (n = 3), glenoid loosening (n = 3), osteolysis (n = 1), or notching (n = 1). Fourteen of the 151 patients (9.2%) who had surgery prior to RSA required revision after RSA. Having shoulder surgery prior to RSA was associated with higher rates of subsequent revision after RSA. CONCLUSION: Overall, survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus RSA is high, and prostheses implanted in native shoulders have lower rates of revision at midterm follow-up. Instability (1.9%) was the most common reason for revision.

Delay to Arthroscopic Rotator Cuff Repair Is Associated With Increased Risk of Revision Rotator Cuff Surgery.

The purpose of this study was to determine the association between time from the diagnosis of rotator cuff tear to repair and the rate of subsequent revision surgery for re-tear. A national insurance database was queried from 2007 to 2016 for patients who underwent arthroscopic rotator cuff repair after a diagnosis of rotator cuff tear with minimum 5-year follow-up. On the basis of time from diagnosis to repair, patients were stratified into an early (<6 weeks), a routine (between 6 weeks and 12 months), or a delayed (>12 months) repair cohort. The rates of subsequent revision rotator cuff repair were compared pairwise between cohorts with Pearson's chi-square tests. Multivariate logistic regression was used to adjust for patient demographics and comorbidity burden. A total of 2759 patients were included, with 1510 (54.7%) undergoing early repair, 1104 (40.0%) undergoing routine repair, and 145 (5.3%) having delayed repair. The overall revision rate at 5-year follow-up was 9.6%. The revision rate was higher in the delayed group (15.2%) relative to the early (9.9%) and routine (8.3%) groups (P=.048 and P=.007, respectively). On multivariate analysis, delayed repair was associated with increased odds of revision surgery (odds ratio, 1.97; P=.009) compared with routine repair. Delayed rotator cuff repair beyond 12 months of diagnosis was associated with an increased risk of undergoing subsequent revision rotator cuff repair while controlling for age and comorbidity burden. [Orthopedics. 2020;43(6):340-344.].

Failed Proximal Humerus Osteosynthesis Using Intramedullary Fibular Strut Allograft Conversion to Reverse Shoulder Arthroplasty.

Comminuted proximal humerus fractures are more frequently being treated utilizing an intramedullary fibular strut allograft to assist with open reduction internal fixation. Although this technique has led to improved outcomes, avascular necrosis, rotator cuff failure, and/or prominent hardware may still occur necessitating conversion to reverse shoulder arthroplasty. The presence of an intramedullary strut allograft makes this conversion technically demanding and creates certain potential complications unique to this group. This manuscript details the conversion of a proximal humerus open reduction internal fixation with a fibular strut allograft to reverse shoulder arthroplasty including presurgical workup, surgical techniques, and pitfalls for undertaking this increasingly common scenario.

Predictors of patient satisfaction after reverse shoulder arthroplasty.

HYPOTHESIS: The aims of this study were to determine patient satisfaction and to identify predictors of satisfaction after reverse shoulder arthroplasty (RSA). We hypothesized that the majority of patients would be satisfied after RSA and that patients with worse preoperative mental and physical health would be less satisfied. METHODS: Satisfaction was assessed 2 years after primary RSA with domains for pain, work, activities, quality of life, and overall satisfaction. Preoperative and postoperative patient-reported factors were measured using the American Shoulder and Elbow Surgeons (ASES) shoulder score, Shoulder Activity Scale score, Short Form 12 (SF-12) mental and physical component summary scores, and visual analog scale (VAS) pain, fatigue, and general health scores. Pearson correlations were used to determine the relationship between patient-reported factors and satisfaction. Multivariate regression was performed to control for potential confounding variables. RESULTS: A total of 161 patients were evaluated at 2 years postoperatively. Patients were "very satisfied" in an average of 3.3 of the 5 domains. Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction, with correlation coefficients ranging from 0.27 to 0.49. On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery (P = .005). In addition, patients with worse VAS fatigue (P = .011) and SF-12 mental (P = .034) and physical (0.011) component summary scores preoperatively had lower satisfaction. CONCLUSION: Improvements in pain and outcome scores are associated with increased satisfaction. Patients with higher shoulder function, worse physical health, and worse mental health prior to surgery are more likely to have lower satisfaction after RSA.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery.

BACKGROUND: Considered the gold standard of study designs, randomized controlled trials' (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery. METHODS: A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold. RESULTS: Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis. CONCLUSIONS: The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Preoperative patient expectations of elective reverse shoulder arthroplasty.

BACKGROUND: The purpose of this study was to determine patients' preoperative expectations before primary elective reverse shoulder arthroplasty (RSA). We hypothesized that younger patients, patients with better preoperative function, patients with shoulder osteoarthritis (OA), and patients with no prior joint replacements would have higher expectations of RSA. METHODS: We prospectively studied 333 primary RSAs performed for cuff tear arthropathy (n = 242), OA (n = 68), or post-traumatic arthritis (n = 23). Expectations were assessed preoperatively using the Hospital for Special Surgery's shoulder surgery expectations survey. Preoperative patient-reported measures were assessed with the American Shoulder and Elbow Surgeons shoulder score; Shoulder Activity Scale score; Short Form 12 mental component and physical component scores; and visual analog scale scores for pain, fatigue, and general health. A Poisson regression model was performed to control for potential confounding variables. RESULTS: Relief of night-time pain, relief of daytime pain, improvement in self-care, improvement in the ability to drive or put on a seat belt, and improvement in the ability to perform daily activities were reported as "very important" by approximately half of patients. No association was found between age and overall expectations. Multivariate analysis showed that better preoperative Shoulder Activity Scale and Short Form 12 physical component scores were associated with greater expectations (P < .001). OA was associated with greater expectations compared with cuff tear arthropathy (P < .001). A history of either contralateral RSA or any joint replacement was associated with lower expectations (P < .001). CONCLUSION: Patients have the highest expectations for pain relief and the performance of simple tasks after RSA. Patients with higher preoperative function, OA, and no previous joint replacements have greater expectations of RSA.

Fragility of randomized clinical trials of treatment of clavicular fractures.

BACKGROUND: Statistical significance, as reported by the P value, has traditionally been the most commonly reported way to determine whether a difference exists between clinical interventions. Unfortunately, P values alone confer little about the robustness of a study's conclusions. An emerging metric, the fragility index (FI), helps to address this challenge by quantifying the number of events per outcome group that would need to be reversed to the alternative outcome in order to raise the P value above the 0.05 threshold. METHODS: Using systematic search strategy, we identified randomized controlled trials (RCTs) pertaining to clavicular fractures published in the last decade (2007-2017). Studies included for analysis involved 2 parallel arms, were published in English, allocated patients to treatment and control arms in a 1:1 ratio, and reported statistical significance (P < .05) for dichotomous variables. The FI was determined based on the Fisher exact test, using previously published methods. RESULTS: Fifteen RCTs were included. The median FI was 2 (range, 0-17). Eleven studies (73.3%) had an FI of 2 or less. Seven of the trials (46.7%) reported that the number of patients lost to follow-up exceeded the FI. CONCLUSIONS: The median FI reported in the recent literature on clavicular fractures is only 2. The FI is a useful metric to analyze the robustness of study conclusions that should complement other methods of critical data evaluation, including the P value or effect sizes. Future efforts are needed to increase institutional collaboration and patient recruitment to strengthen the robustness of RCT conclusions, especially in the realm of clavicular fracture management.

Chondral Delamination of Fresh Osteochondral Allografts after Implantation in the Knee: A Matched Cohort Analysis.

INTRODUCTION: Delamination of the chondral surface of an osteochondral allograft (OCA) from the underlying cancellous bone has been described as a mode of failure after implantation in the knee. Our hypothesis was that increased storage time of the OCA is associated with increased risk of graft delamination after implantation. METHODS: Prospective data on 13 patients with evidence of OCA delamination identified on magnetic resonance imaging or during subsequent surgery from 2000 to 2015 were reviewed. A cohort of 33 patients without evidence of graft delamination were then matched to the delamination group based on recipient age, sex, body mass index (BMI), and chondral defect location. The matched cohort size was established based on a power calculation for determining differences in OCA storage times. All patients had a minimum 2-year follow-up. RESULTS: There was no difference in donor age, donor sex, and graft storage time between groups (30 vs. 31 days, P = 0.78). There were no differences between number of previous ipsilateral knee surgeries (1.8 vs. 0.84, P = 0.26), BMI (26.8 vs. 25.0 kg/m2, P = 0.31), total chondral defect size (6.5 vs. 5.8 cm2, P = 0.41) or preoperative Marx activity scores between groups. CONCLUSION: There is no association between OCA storage time, activity level scores, or number of previous ipsilateral knee surgeries and graft delamination in our patient population. Further work is needed to identify the etiology for this mode of failure of OCAs.

Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty.

BACKGROUND: The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes. METHODS: Patients undergoing primary RSA completed the Hospital for Special Surgery's Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors. RESULTS: We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (ß = 7.0, P = .048) and VAS pain scores (ß = -5.9, P = .047) as well as 2-year improvement of VAS pain (ß = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (ß = 2.8, P = .020). CONCLUSION: A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA.