Job satisfaction and practice characteristics of shoulder and elbow surgeons: a survey of American Shoulder and Elbow Surgeons society members.

BACKGROUND: The purpose of this study is to assess the current trends in fellowship training, career satisfaction, practice characteristics, and surgical case volume among shoulder and elbow surgeons. METHODS: A web-based, anonymous 25-item survey was sent to the membership of the American Shoulder and Elbow Surgeons (ASES) in October of 2022. Questions posed included respondent demographics, fellowship training, career satisfaction, practice characteristics, and surgical case characteristics. Descriptive statistics were performed to report demographic information, assess job and training satisfaction rates, and evaluate practice characteristics. Chi-squared and independent samples t-tests were performed to analyze satisfaction rates, job applications, and surgical case volume with regard to years in practice and practice setting. RESULTS: Twenty percent (243/1248) of ASES members satisfactorily completed the survey. Of the 243 ASES member respondents, 97% (236/243) stated that they would pursue their fellowship training again. Ninety-eight percent (239/243) of respondents were satisfied with their specialty choice. One-hundred percent (242/243) were satisfied with their training in shoulder. Seventy-two percent (176/243) were satisfied with their training in elbow. Seventy-four percent (179/243) were satisfied with their job availability and 85% (207/243) were satisfied with their job location. The mean total number of orthopedic surgical cases per year was 393 ± 171. The mean total number of shoulder cases per year was 253 ± 149. The mean total number of elbow cases per year was 41 ± 41. Physicians who have been in practice for 11 years or more were comparatively more satisfied (90% vs. 80%) with their job location (P value = .008) and job availability (81% vs. 64%, P value < .001). Additionally, senior surgeons completed more orthopedic (431 vs. 347, P value < .001) and shoulder (279 vs. 220, P value = .002) cases annually than surgeons earlier in their careers. Satisfaction rates, job applications, and surgical case volume did not associate with practice setting. CONCLUSIONS: The majority of ASES member shoulder and elbow surgeons are satisfied with their training, their case volume and complexity, and their specialty choice. Fewer surgeons are satisfied with their elbow training and overall elbow case volume remains low among shoulder and elbow surgeons. Shoulder and elbow surgeons earlier in their careers perform fewer surgical cases, are less satisfied with their job availability and location, and completed more job applications for their first job after fellowship when compared to more senior surgeons.

Hemiarthroplasty versus total shoulder arthroplasty in B2 glenoids with an intact rotator cuff: a long-term matched cohort analysis.

Background: Walch B2 glenoids present unique challenges to the shoulder arthroplasty surgeon, particularly in young, active patients who may wish to avoid the restrictions typically associated with an anatomic total shoulder arthroplasty (TSA). Long-term data are limited when comparing hemiarthroplasty (HA) and TSA for patients with an intact rotator cuff. The purpose of our study was to compare the long-term outcomes of HA vs. TSA in a matched analysis of patients with B2 glenoids, primary osteoarthritis (OA), and an intact rotator cuff. Methods: A retrospective review was performed of all patients who underwent HA or TSA between January 2000 and December 2011 at a single institution. Inclusion criteria were primary OA, Walch B2 glenoid morphology, an intact rotator cuff intraoperatively, at least 2 years of clinical follow-up, or revision within 2 years of surgery. Fifteen HAs met inclusion criteria and were matched 1:2 with 30 TSAs using age, sex, body mass index, and implant selection. Clinical outcomes including range of motion (ROM), visual analog scale (VAS) for pain, subjective shoulder value score, American Shoulder and Elbow Surgeons (ASES) score, complications, and revisions were recorded. Postoperative radiographs were reviewed to assess for stem loosening, humeral head subluxation, glenoid loosening, and glenoid erosion. Results: A total of 15 HAs and 30 TSAs met inclusion criteria at a mean follow-up of 9.3 years. The mean age at the time of surgery was 60.2 years for HA and 65.4 years for TSA (P = .08). Both cohorts had significant improvements in ROM, subjective shoulder value, and VAS pain scores (P < .001). TSA had higher postoperative ASES scores compared to HA (P = .03) and lower postoperative VAS pain scores (P = .03), although the decrease in pain from preoperatively to final follow-up was not significantly different between HA and TSA (P = .11). HAs were more likely to have posterior humeral subluxation (P < .001) and stem lucencies (P = .02). Revisions occurred in 11.1% of the cohort with no difference for HA and TSA (P = .73). Conclusions: At nearly 10 years of follow-up, HA and TSA both showed significant improvements in ROM and pain when performed for primary glenohumeral OA in B2 glenoids with intact rotator cuffs. Compared to HA, TSAs had less posterior humeral subluxation, less stem lucencies, higher ASES scores, and lower postoperative VAS pain scores. However, our study failed to demonstrate a difference in ROM, complication, or revision rates between HA and TSA.

Surgical management of osteoarthritis in the shoulder and elbow.

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Effects of purified exosome product on rotator cuff tendon-bone healing in vitro and in vivo.

Exosomes have multiple therapeutic targets, but the effects on healing rotator cuff tear (RCT) remain unclear. As a circulating exosome, purified exosome product (PEP) has the potential to lead to biomechanical improvement in RCT. Here, we have established a simple and efficient approach that identifies the function and underlying mechanisms of PEP on cell-cell interaction using a co-culture model in vitro. In the in vivo trial, adult female Sprague-Dawley rats underwent unilateral surgery to transect and repair the supraspinatus tendon to its insertion site with or without PEP. PEP promoted the migration and confluence of osteoblast cells and tenocytes, especially during direct cell-cell contact. Expression of potential genes for RCT in vitro and in vivo models were consistent with biomechanical tests and semiquantitative histologic scores, indicating accelerated strength and healing of the RC in response to PEP. Our observations suggest that circulating exosomes provide an effective option to improve the healing speed of RCT after surgical repair. The regeneration of enthesis following PEP treatment appears to be related to a mutually reinforcing relationship between direct cell-cell contact and PEP activity, suggesting a dual approach to the healing process.

Editorial Commentary: Elbow Arthroscopy Is a Safe Procedure. Sure.

Elbow arthroscopy is a procedure that is of great potential use and yet also of grave potential risks. To balance the risk-versus-reward consideration, one must be aware of the potential complications associated with this procedure, weigh them against the potential advantages, and understand one's own skills and familiarity with the procedure. There is no doubt that elbow arthroscopy has changed and even revolutionized our management of pathology about the elbow; however, one must bear in mind that this comes at a risk of complications that cannot be reduced to zero.

Anchor placement to glenoid rim during Bankart repair recreates contact area of anterior capsulolabral complex on glenoid better than onto articular surface.

PURPOSE: This study aimed to compare the contact areas of Bankart repair with suture anchors placed on the articular surface of the glenoid versus at the rim of the glenoid because it is unclear which technique most effectively restores the footprint after Bankart repair. METHODS: Ten fresh frozen cadaveric shoulders (mean age 70.7 years) were dissected. The attachment site of the capsulolabral complex from the 1 o' clock position to the 6 o'clock position was marked with ink, and the contact area of the anterior-inferior capsulolabral complex on the glenoid neck was measured using imageJ. Bankart lesions were created, and two types of Bankart repair were performed on each specimen. The suture anchors were inserted at the glenoid rim (Rim group) and onto the glenoid articular surface 2 mm from the rim (Surface group). Using pressure-sensitive films, we examined the interface contact area. RESULTS: The Rim group recreated 64.9% of the native surface area, while the Surface group recreated 47.3% of the area. The Rim group recreated significantly greater contact area compared to the Surface group (P = 0.0008). CONCLUSION: The anchor placement to the glenoid rim recreates the footprint of the capsulolabral complex on the anterior inferior glenoid better than the anchor placement onto the articular surface.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate.

BACKGROUND: Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology. METHODS: Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years. RESULTS: There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation. CONCLUSIONS: ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

Managing Glenoid Deformity in Shoulder Arthroplasty: Role of New Technology (Computer-Assisted Navigation and Patient-Specific Instrumentation).

The glenoid is considered a weak link in total shoulder arthroplasty because failure on the glenoid side is one of the most common reasons for revision of total shoulder arthroplasty. Glenoid wear is commonly seen in glenohumeral arthritis and compromises glenoid bone stock and also alters the native version and inclination of the glenoid. It is critical to recognize glenoid wear and correct it intraoperatively to avoid component malposition, which can negatively affect the survivorship of the glenoid implant. The end point of correction for the glenoid wear in shoulder arthroplasty is controversial, but anatomic glenoid component positioning is likely to improve long-term survivorship of the total shoulder arthroplasty. Preoperative three-dimensional (3-D) computer planning software, based on CT, is commercially available. It allows the surgeon to plan implant type (anatomic versus reverse), size, and position on the glenoid, and also allows for templating deformity correction using bone graft and/or augments. Guidance technology in the form of computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) allows the surgeon to execute the preoperative plan during surgery with a greater degree of accuracy and precision and has shown superiority to standard instrumentation. However, the proposed benefits of this technology including improved glenoid survivorship, reduced revision arthroplasty rate and cost-effectiveness have not yet been demonstrated clinically. In this review, we present the current evidence regarding PSI and CAS in managing glenoid deformity in total shoulder arthroplasty.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle.

BACKGROUND: Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion. METHODS: A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients' demographics, time to union, and postoperative complications were collected. RESULTS: A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal. CONCLUSION: The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.

Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates.

BACKGROUND: The early results of reverse shoulder arthroplasty (RSA) were influenced to some extent by the use of first-generation implants and surgeons' learning curves, resulting in relatively high reoperation rates. The purpose of this study was to quantify the burden of and identify the indications for reoperation after primary RSA using contemporary implants and techniques. METHODS: A retrospective review of 1649 primary RSAs implanted consecutively between 2009 and 2015 at a single institution was conducted. All arthroplasties were performed by 5 fellowship-trained shoulder surgeons at a tertiary referral center. Demographic characteristics, indications for primary RSA, and reoperations were analyzed and categorized for trends associated with each type of reoperation performed. RESULTS: A total of 39 reoperations (2.37%) were performed for a variety of indications. Overall, only a few patients with infection or instability required reoperation (0.55%). The most common indications for reoperation were related to the humeral component (1.03%); the majority of humeral component complications were related to a specific design flaw of 1 implant system. RSAs performed for proximal humeral fracture sequelae more commonly underwent reoperation owing to instability or humeral component-related issues; all 4 cases of aseptic humeral stem loosening occurred in the setting of proximal humeral fracture sequela treatment. Only 0.36% of all primary RSAs required reoperation because of glenoid complications. CONCLUSIONS: Primary RSA performed with contemporary implants and surgical techniques seems to be associated with a very low rate of reoperation. The most common reasons for reoperation were humeral component fracture for 1 particular implant, humeral loosening, dislocation, infection, and glenoid failure, each occurring at a rate under 1%.

Engineered tendon-fibrocartilage-bone composite and bone marrow-derived mesenchymal stem cell sheet augmentation promotes rotator cuff healing in a non-weight-bearing canine model.

Reducing rotator cuff failure after repair remains a challenge due to suboptimal tendon-to-bone healing. In this study we report a novel biomaterial with engineered tendon-fibrocartilage-bone composite (TFBC) and bone marrow-derived mesenchymal stem cell sheet (BMSCS); this construct was tested for augmentation of rotator cuff repair using a canine non-weight-bearing (NWB) model. A total of 42 mixed-breed dogs were randomly allocated to 3 groups (n = 14 each). Unilateral infraspinatus tendon underwent suture repair only (control); augmentation with engineered TFBC alone (TFBC), or augmentation with engineered TFBC and BMSCS (TFBC + BMSCS). Histomorphometric analysis and biomechanical testing were performed at 6 weeks after surgery. The TFBC + BMSCS augmented repairs demonstrated superior histological scores, greater new fibrocartilage formation and collagen fiber organization at the tendon-bone interface compared with the controls. The ultimate failure load and ultimate stress were 286.80 ± 45.02 N and 4.50 ± 1.11 MPa for TFBC + BMSCS group, 163.20 ± 61.21 N and 2.60 ± 0.97 MPa for control group (TFBC + BMSCS vs control, P = 1.12E-04 and 0.003, respectively), 206.10 ± 60.99 N and 3.20 ± 1.31 MPa for TFBC group (TFBC + BMSCS vs TFBC, P = 0.009 and 0.045, respectively). In conclusion, application of an engineered TFBC and BMSCS can enhance rotator cuff healing in terms of anatomic structure, collagen organization and biomechanical strength in a canine NWB model. Combined TFBC and BMSCS augmentation is a promising strategy for rotator cuff tears and has a high potential impact on clinical practice.

Hemiarthroplasty Is an Option for Patients Older Than 70 Years With Glenohumeral Osteoarthritis.

Hemiarthroplasty (HA) of the shoulder has several potential advantages over total shoulder arthroplasty (TSA), particularly in the elderly population. This study reviewed long-term results of HA and TSA in patients older than 70 years with glenohumeral osteoarthritis. During a 30-year period, 403 shoulders had undergone HA (n=74) or TSA (n=329) for glenohumeral osteoarthritis. Outcome measures included pain, range of motion, and postoperative modified Neer ratings. All patients were included in the mortality and revision analyses. A total of 289 shoulders (44 HAs and 245 TSAs; mean patient age, 75 years) with a minimum of 5 years of follow-up or follow-up until revision were included. Both groups showed significant improvements in pain, abduction, and external rotation. No significant differences were detected between groups in postoperative pain, range of motion, or modified Neer ratings. Operative time was significantly lower in the HA group. There was no statistically significant difference detected in implant revision-free survival between TSA and HA (hazard ratio, 3.09) or in overall survival hazard ratio. At long-term follow-up, both HAs and TSAs provided good function in the elderly population. Patients who underwent TSA and patients who underwent HA had similar results, but the latter had a shorter operative time and lower revision rate. Hemiarthroplasty is a reasonable option for patients older than 70 years with end-stage glenohumeral osteoarthritis. [Orthopedics. 2018; 41(4):222-228.].

Novel engineered tendon-fibrocartilage-bone composite with cyclic tension for rotator cuff repair.

Surgical repair of rotator cuff tears presents a significant clinical challenge with high failure rates and inferior functional outcomes. Graft augmentation improves repair outcomes; however, currently available grafting materials have limitations. Although cell-seeded decellularized tendon slices may facilitate cell infiltration, promote tendon incorporation, and preserve original mechanical strength, the unique fibrocartilage zone is yet to be successfully reestablished. In this study, we investigated the biological and mechanical properties of an engineered tendon-fibrocartilage-bone composite (TFBC) with cyclic tension (3% strain; 0.2 Hz). Decellularized TFBCs seeded with bone marrow-derived mesenchymal stem cell (BMSCs) sheets and subjected to mechanical stimulation for up to 7 days were characterised by histology, immunohistochemistry, scanning electron microscopy, mechanical testing, and transcriptional regulation. The decellularized TFBC maintained native enthesis structure and properties. Mechanically stimulated TFBC-BMSC constructs displayed increased cell migration after 7 days of culture compared with static groups. The seeded cell sheet not only integrated well with tendon scaffold but also distributed homogeneously and aligned to the direction of stretch under dynamic culture. Developmental genes were regulated including scleraxis, which was significantly upregulated with mechanical stimulation. The Young's modulus of the cell-seeded constructs was significantly higher compared with the noncell-seeded controls. In conclusion, the results of this study reveal that the TFBC-BMSC composite provides an ideal multilayer construct for cell seeding and growth, with mechanical preconditioning further enhances cell penetration and differentiation. The BMSC cell sheet revitalised TFBC in conjunction with mechanical stimulation could serve as a novel and primed biological patch to improve rotator cuff repair.

Assessing glenosphere position: superior approach versus deltopectoral for reverse shoulder arthroplasty.

BACKGROUND: The anterosuperior (AS) approach for reverse total shoulder arthroplasty (RTSA) has been reported as a risk factor for baseplate malposition because of potential difficulty in glenoid exposure. The objective of this study was to compare glenoid baseplate position between the AS and deltopectoral (DP) approaches in relation to the surgeon's experience and to evaluate the effect of placement on clinical outcomes. METHODS: There were 109 shoulders that underwent RTSA for cuff tear arthropathy or osteoarthritis with cuff tearing by a single surgeon. The AS approach was used in 87 shoulders. Clinical, radiographic, and functional outcomes were assessed for all patients with a minimum of 2 years of follow-up. Initial postoperative radiographs of all 109 shoulders were assessed for baseplate positioning. RESULTS: The mean change in glenoid inclination was 3.0° inferior with the AS approach and 2.5° inferior with the DP approach (P = .68). Pain scores (P = .14), range of motion, and American Shoulder and Elbow Surgeons scores (P = .16) improved in both groups, without a difference between approach. Scapular notching was noted in 68.5% of AS shoulders and 72.4% of DP shoulders (P = .78). Over time, there was a trend to place the glenoid baseplate more caudal with less inferior tilt. DISCUSSION AND CONCLUSION: Both approaches produce similar baseplate position, clinical outcomes, and rates of scapular notching when they are used for RTSA. Attempts to inferiorize the glenoid baseplate through the AS approach may increase the risk of superior inclination.

Intra-articular injection of a substance P inhibitor affects gene expression in a joint contracture model.

Substance P (SP), a neurotransmitter released after injury, has been linked to deregulated tissue repair and fibrosis in musculoskeletal tissues and other organs. Although SP inhibition is an effective treatment for nausea, it has not been previously considered as an anti-fibrotic therapy. Although there are extensive medical records of individuals who have used SP antagonists, our analysis of human registry data revealed that patients receiving these antagonists and arthroplasty are exceedingly rare, thus precluding a clinical evaluation of their potential effects in the context of arthrofibrosis. Therefore, we pursued in vivo studies to assess the effect of SP inhibition early after injury on pro-fibrotic gene expression and contractures in an animal model of post-traumatic joint stiffening. Skeletally mature rabbits (n = 24) underwent surgically induced severe joint contracture, while injected with either fosaprepitant (a selective SP antagonist) or saline (control) early after surgery (3, 6, 12, and 24 h). Biomechanical testing revealed that differences in mean contracture angles between the groups were not statistically significant (P = 0.27), suggesting that the drug neither mitigates nor exacerbates joint contracture. However, microarray gene expression analysis revealed that mRNA levels for proteins related to cell signaling, pro-angiogenic, pro-inflammatory, and collagen matrix production were significantly different between control and fosaprepitant treated rabbits (P < 0.05). Hence, our study demonstrates that inhibition of SP alters expression of pro-fibrotic genes in vivo. This finding will motivate future studies to optimize interventions that target SP to reduce the formation of post-traumatic joint contractures.

Quantifying extensibility of rotator cuff muscle with tendon rupture using shear wave elastography: A cadaveric study.

Surgical repair for large rotator cuff tear remains challenging due to tear size, altered muscle mechanical properties, and poor musculotendinous extensibility. Insufficient extensibility might lead to an incomplete reconstruction; moreover, excessive stresses after repair may result in repair failure without healing. Therefore, estimates of extensibility of cuff muscles can help in pre-surgical planning to prevent unexpected scenarios during surgery. The purpose of this study was to determine if quantified mechanical properties of the supraspinatus muscle using shear wave elastography (SWE) could be used to predict the extensibility of the musculotendinous unit on cadaveric specimens. Forty-five fresh-frozen cadaveric shoulders (25 intact and 20 with rotator cuff tear) were used for the study. Passive stiffness of 4 anatomical regions in the supraspinatus muscle was first measured using SWE. After detaching the distal edge of supraspinatus muscle from other cuff muscles, the detached muscle was axially pulled with the scapula fixed. The correlation between the SWE modulus and the extensibility of the muscle under 30 and 60N loads was assessed. There was a significant negative correlation between SWE measurements and the experimental extensibility. SWE modulus for the anterior-deep region in the supraspinatus muscle showed the strongest correlation with extensibility under 30N (r=0.70, P<0.001) and 60N (r=0.68, P<0.001). Quantitative SWE assessment for the supraspinatus muscle was highly correlated with extensibility of musculotendinous unit on cadaveric shoulders. This technique may be used to predict the extensibility for rotator cuff tears for pre-surgical planning.

The effect of scapular position on subacromial contact behavior: a cadaver study.

BACKGROUND: Patients with subacromial impingement were reported to show abnormal scapular positions during shoulder elevation. However, the relationship between the scapular positions and subacromial impingement is unclear. The purpose of this study was to biomechanically determine the effect of scapular position on subacromial contact behavior by using fresh frozen cadavers. METHODS: The peak contact pressure on the coracoacromial arch was measured with a flexible tactile force sensor in 9 fresh frozen cadaver shoulders. The measurement was performed during passive glenohumeral elevation in the scapular plane ranging from 30° to 75°. The scapular downward and internal rotations and anterior tilt were simulated by tilting the scapula in 5° increments up to 20°. The measurement was also performed with combination of scapular downward and internal rotations and anterior tilt positions. RESULTS: The peak contact pressure decreased linearly with anterior tilt, and a significant difference between neutral scapular position (1.06 ± 0.89 MPa) and anterior tilt by 20° (0.46 ± 0.18 MPa) was observed (P < .05). However, the scapular positioning in the other directions did not change the peak contact pressure significantly. Furthermore, any combination of abnormal scapular positions did not affect peak contact pressure significantly. CONCLUSION: Scapular anterior tilt decreased peak contact pressure during passive shoulder elevation. In addition, scapular downward and internal rotations had little effect on peak contact pressure. The abnormal scapular motion reported in previous studies might not be directly related to symptoms caused by subacromial impingement.

Effect of smoking on complications following primary shoulder arthroplasty.

BACKGROUND: The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). METHODS: All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery. RESULTS: The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio [HR], 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99). CONCLUSIONS: This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.

Repairing the Capsule to the Transferred Coracoid Preserves External Rotation in the Modified Latarjet Procedure.

BACKGROUND: It is not clear whether the anterior capsule should be repaired to the coracoid process or to the native glenoid during the modified Latarjet procedure. We investigated joint stability and range of motion of the shoulder after the modified Latarjet procedure with both of these methods of capsular repair. METHODS: Eighteen fresh-frozen cadaveric shoulders were used. After a Bankart lesion and 6-mm glenoid defect were created, the coracoid process was transferred to the glenoid and fixed with screws. The anterior capsule was repaired either to the coracoid process (coracoid group) or to the native glenoid (glenoid group). The ranges of internal and external axial rotation were measured with the arm at 0° and 60° of glenohumeral abduction. The range of motion was measured with a constant torque of 200 N-mm. Joint stability was measured using a custom stability testing device. The stability ratio in the anterior-posterior direction was measured with the arm at maximal external rotation and neutral rotation. RESULTS: The range of external rotation was greater at both 0° and 60° of abduction in the coracoid group compared with the glenoid group (p < 0.05). The range of internal rotation was not significantly different between groups. The end-range stability ratio was not significantly different between groups, but the mid-range stability ratio was significantly greater in the glenoid group. CONCLUSIONS: Because the difference in the mid-range stability may not be clinically relevant, we recommend repairing the capsule to the coracoid, as that preserves the range of motion in external rotation. CLINICAL RELEVANCE: Repairing the capsule to the transferred coracoid during the modified Latarjet procedure appears to be beneficial to avoid the limited range of motion in external rotation, but the direct contact of the humeral head and the transferred coracoid might confer a risk of osteoarthritis. Long-term consequences in the clinical setting need to be clarified.