Defining Patient Satisfaction after Reverse Total Shoulder Arthroplasty: A Systematic Review.

BACKGROUND: The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery. METHODS: A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index (BMI). Follow-up duration, indication for surgery, and patient reported outcome measures (PROMs) relating to patient satisfaction were also recorded. RESULTS: There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7 to 87.8%, depending on patient satisfaction PROMs. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy (CTA) or massive rotator cuff tear (MRCT). CONCLUSION: This systematic review demonstrated that patients who undergo rTSA for either GHOA, CTA, or MRCT are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges.

BACKGROUND: As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. METHODS: This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant. RESULTS: There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82). CONCLUSION: SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Shoulder periprosthetic joint infection is associated with increased mortality.

BACKGROUND: Periprosthetic joint infections (PJIs) are a catastrophic complication after shoulder arthroplasty and may be associated with an increased mortality risk, as seen in hip and knee arthroplasty. Shoulder PJI organisms differ from hip and knee infections, as lower-virulence organisms, such as Cutibacterium acnes, are more commonly encountered. This study evaluated the association between shoulder PJI and mortality. METHODS: We retrospectively identified 411 patients who underwent revision shoulder arthroplasty from 2007 to 2020 at a single institution. 2018 International Consensus Meeting on Musculoskeletal Infection criteria were used to categorize each case as definite, probable, possible, or unlikely PJI. Mortality rate was assessed by performing chart reviews and an obituary search. Revision cases were grouped into a septic cohort (definite and probable PJI) and an aseptic cohort (possible and unlikely PJI). Kaplan-Meier analyses were performed to compare survival between septic and aseptic groups. The log-rank test was used to compare cumulative survival distributions and survival rates at 90 days, 6 months, 1 year, 2 years, and 5 years. Demographic information, Charlson Comorbidity Index (CCI), and culture data were collected. PJI organisms were categorized as virulent or nonvirulent per an infectious disease specialist, and predictors of mortality were determined by performing stepwise logistic regression analyses. RESULTS: The overall mortality rate was significantly greater (P < .001) in the septic group (20.5%) than in the aseptic group (6.6%). When evaluating time from revision surgery to death, patients with PJI had significantly greater mortality compared with those undergoing aseptic revision at 2 years (7.7% vs. 2.1%, P = .01) and 5 years (17% vs. 5.1%, P < .001). Body mass index, CCI, race, sex, and age were not significantly different between groups. Groups differed in utilization of 2-staged procedures (65% septic, 9% aseptic, P < .001). Multivariate regression analysis found that the variables most associated with mortality were septic revision, 2-staged procedures, and CCI. In the septic group, patients with C acnes PJI had a significantly lower mortality rate when compared to PJI from any other offending organism (3.1% vs. 48.4%, P = .001). CONCLUSION: Revision shoulder arthroplasty in the setting of PJI not only carries severe functional consequences for patients but is also associated with an increased mortality risk. Furthermore, C acnes infections are associated with a more favorable survival profile than PJI resulting from other organisms. Continued efforts to decrease shoulder arthroplasty infection rates are warranted and may influence long-term survival.

Complications after operative treatment of high-grade acromioclavicular injuries.

BACKGROUND: Treatment of Rockwood type III-V acromioclavicular (AC) joint injuries remains controversial. Numerous reconstruction techniques have been proposed. The purpose of this study was to describe the complication profile in a large cohort of patients who underwent surgical management of AC joint separations using a variety of reconstruction strategies. METHODS: All patients who underwent surgery for AC joint injuries from 2013 to 2019 at a single institution were identified. Chart review was performed to capture patient demographics, radiographic measurements, operative techniques, postoperative complications, and revision surgery. Structural failure was defined as a radiographic loss of reduction of greater than 50% when comparing immediate and final postoperative imaging. Logistic regression analysis was performed to identify risk factors for complications and revision surgery. RESULTS: Of the 279 patients included in the study, 66 (24%) had type III separations, 20 (7%) type IV, and 193 (69%) type V. Fifty-three percent underwent surgery acutely (<6 weeks of injury), and 40% were chronic (>3 months). A total of 252 of the 279 surgeries (90%) were performed open and 27 (10%) were arthroscopically assisted. Allograft was used in 164 of 279 (59%) cases. Specific operative techniques (with or without allograft) included hook plating (1%), modified Weaver Dunn (16%), cortical button fixation (18%), and suture fixation (65%). At mean 28-week follow-up, 108 complications were identified in 97 patients (35%). Complications were identified at mean 20 ± 21 weeks. Sixty-nine structural failures (25%) were identified. Persistent AC joint pain requiring injection, clavicle fracture, adhesive capsulitis, and hardware complications were the other most common complications. Twenty-one patients (8%) underwent unplanned revision surgery at mean 38 ± 28 weeks after the index procedure, with the most common indication for structural failure, hardware complications, or fracture of the clavicle or coracoid. Patients who had surgery after 6 weeks from injury had a significantly greater risk of having a complication (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.34-7.77, P = .009) and a significantly greater risk of having structural failure (OR 2.65, 95% CI 1.38-5.28, P = .004). Patients who had an arthroscopic technique had a greater risk of structural failure (P = .002). Complications, structural failure, and revision surgery were not significantly correlated with use of allograft or specific operative techniques. CONCLUSION: Surgical management of AC joint injuries is associated with a relatively high complication profile. Loss of reduction in the postoperative period is common. However, the revision surgery rate is low. These findings are important for patient preoperative counseling.

Cemented versus uncemented fixation of second-generation Trabecular Metal glenoid components: minimum 5-year outcomes.

BACKGROUND: Total shoulder arthroplasty (TSA) with second-generation Trabecular Metal™ implants (Zimmer, Warsaw, IN, USA) has shown good short-term outcomes. Differences in outcomes between cemented and uncemented fixation are unknown. This study compared the clinical, radiographic, and patient-rated outcomes of TSA with cemented vs. uncemented TM glenoids at minimum 5-year follow-up. METHODS: Patients who underwent anatomic TSA with second-generation TM glenoid components for primary osteoarthritis were identified for minimum 5-year follow-up. The patients were divided into 2 groups: cemented and uncemented glenoid fixation. Outcome measures included implant survival, patient-rated outcome scores (Patient-Reported Outcomes Measurement Information System [PROMIS] and American Shoulder and Elbow Surgeons scores), shoulder range of motion, and radiographic analysis. Findings were compared between groups. RESULTS: The study included 55 shoulders: 27 in the cemented group (21 with full radiographic follow-up) and 28 in the uncemented group (22 with full radiographic follow-up). Both groups had similar follow-up times (6.6 years in cemented group vs. 6.7 years in uncemented group, P = .60). Moreover, the groups did not differ significantly in sex composition, age at the time of surgery, or preoperative Walch glenoid grade distribution. No patients required revision surgery. The 2 groups had similar preoperative range of motion, but patients in the uncemented group had greater follow-up forward flexion (P = .03), external rotation (P < .01), and lateral elevation (P = .03) than did patients in the cemented group. PROMIS scores were not significantly different between groups. American Shoulder and Elbow Surgeons scores were similar (89.8 in cemented group vs. 94.1 in uncemented group, P = .21). Mid-term radiographs showed a metal debris rate of 24% in the cemented group and 27% in the uncemented group. Although these values were not significantly different (P = .90), the frequency of mild metal debris (grade 1-2), when present, was greater in the uncemented group (grade 2 in 6 shoulders) than in the cemented group (grade 1 in 4 and grade 2 in 1, P = .02). There was a greater presence of mild (grade 1) radiolucent lines in the uncemented group (64%) than in the cemented group (29%, P < .01). No glenoid had evidence of loosening (defined by a change in position or radiolucent lines > 2 mm). The presence of metal debris and radiolucent lines did not have a significant effect on clinical outcomes. CONCLUSION: At minimum 5-year follow-up, TSA patients with TM glenoids demonstrated excellent clinical and patient-reported outcomes with a 100% implant survival rate, regardless of cemented vs. uncemented fixation. However, the uncemented group showed a significantly higher rate of radiolucent lines and a higher frequency of mild metal debris. These radiographic findings did not affect the clinical outcomes, and their implications for long-term outcomes and prosthesis survival is unknown.

Diversity among academic orthopedic shoulder and elbow surgery faculty in the United States.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis of diversity among academic shoulder and elbow surgeons in the United States. METHODS: US shoulder and elbow surgeons who participated in shoulder and elbow fellowship and/or orthopedic surgery resident education as of November 2018 were included. Demographic data (age, gender, race), practice setting, years in practice, academic rank, and leadership roles were collected through publicly available databases and professional profiles. Descriptive statistics were performed and findings were compared between different racial and gender groups. Statistical significance was set at P <.05. RESULTS: A total of 186 orthopedic shoulder and elbow surgeons were identified as participating in shoulder and elbow fellowship and/or orthopedic surgery residency education. Overall, 83.9% were white, 14.5% were Asian, 1.1% were Hispanic, 0.5% were an other race, and 0% were African American. In addition, 94.6% of surgeons were male, whereas 5.4% were female. Further, 64.5% of all surgeons had been in practice for >10 years, and 39.2% worked in an urban setting. Less than half (40.3%) of the surgeons practicing primarily at academic institutions held a professor rank. White surgeons had a significantly greater time in practice vs. nonwhite surgeons (mean 18.8 vs. 12.6 years, P < .01) and were more likely to hold a professor rank (44.0% vs. 21.7%, P = .04). CONCLUSION: Racial and gender diversity among US shoulder and elbow surgeons who participate in fellowship and residency education is lacking. Hispanic, African American, and female surgeons are underrepresented. Efforts should be made to identify the reasons for these deficiencies and address them to further advance the field of orthopedic shoulder and elbow surgery.

What Regions of the Distal Clavicle Have the Greatest Bone Mineral Density and Cortical Thickness? A Cadaveric Study.

BACKGROUND: Osteosynthesis of distal clavicle fractures can be challenging because of comminution, poor bone quality, and deforming forces at the fracture site. A better understanding of regional differences in the bone structure of the distal clavicle is critical to refine fracture fixation strategies, but the variations in BMD and cortical thickness throughout the distal clavicle have not been previously described. PURPOSE: /questions (1) Which distal clavicular regions have the greatest BMD? (2) Which distal clavicular regions have the greatest cortical thickness values? METHODS: Ten distal clavicle specimens were dissected from cadaveric shoulders. Eight specimens were female and two were male, with a mean (range) age of 63 years (59 to 67). The specimens were selected to match known epidemiology, as distal clavicular fractures occur more commonly in older patients with osteoporotic bone, and clavicular fractures in older patients are more common in females than males. The clavicles were then imaged using quantitative micro-CT to create 3-D images. The BMD and cortical thickness were calculated for 10 regions of interest in each specimen. These regions were selected to represent locations where distal clavicular fractures commonly occur and locations of likely bony comminution. Findings were compared between different regions using repeated measures ANOVA with Geiser-Greenhouse correction, followed by Bonferroni method multiple comparison testing. Effect size was also calculated to estimate the magnitude of difference between regions. RESULTS: The four most medial regions of the distal clavicle contained the greatest BMD (anterior intertubercle space 887 ± 31 mgHA/cc, posterior intertubercle space 879 ± 26 mgHA/cc, anterior conoid tubercle 900 ± 21 mgHA/cc, posterior conoid tubercle 896 ± 27 mgHA/cc), while the four most lateral regions contained the least BMD (anterior lateral distal clavicle 804 ± 32 mgHA/cc, posterior lateral distal clavicle 800 ± 38 mgHA/cc, anterior medial distal clavicle 815 ± 27 mgHA/cc, posterior medial distal clavicle 795 ± 26 mgHA/cc). All four most medial regions had greater BMD than the four most lateral regions, with p < 0.001 for all comparisons. For the BMD ANOVA, η was determined to be 0.81, representing a large effect size. The four most medial regions of the distal clavicle also had the greatest cortical thickness (anterior intertubercle space 0.7 ± 0.2 mm, posterior intertubercle space 0.7 ± 0.3 mm, anterior conoid tubercle 0.9 ± 0.2 mm, posterior conoid tubercle 0.7 ± 0.2 mm), while the four most lateral regions had the smallest cortical thickness (anterior lateral distal clavicle 0.2 ± 0.1 mm, posterior lateral distal clavicle 0.2 ± 0.1 mm, anterior medial distal clavicle 0.3 ± 0.1 mm, posterior medial distal clavicle 0.2 ± 0.1 mm). All four most medial regions had greater cortical thickness than the four most lateral regions, with p < 0.001 for all comparisons. For the cortical thickness ANOVA, η was determined to be 0.80, representing a large effect size. No differences in BMDs and cortical thicknesses were found between anterior and posterior regions of interest in any given area. CONCLUSIONS: In the distal clavicle, BMD and cortical thickness are greatest in the conoid tubercle and intertubercle space. When compared with clavicular regions lateral to the trapezoid tubercle, the BMD and cortical thickness of the conoid tubercle and intertubercle space were increased, with a large magnitude of difference. CLINICAL RELEVANCE: Distal clavicular fractures are prone to comminution and modern treatment strategies have centered on the use of locking plate technology and/or suspensory fixation between the coracoid and the clavicle. However, screw pullout or cortical button pull through are known complications of locking plate and suspensory fixation, respectively. Therefore, it seems intuitive that implant placement during internal fixation of distal clavicle fractures should take advantage of the best-available bone. Although osteosynthesis was not directly studied, our study suggests that the best screw purchase in the distal clavicle is available in the areas of the conoid tubercle and intertubercle space, as these areas had the best bone quality. Targeting these areas during implant fixation would likely reduce implant failure and strengthen fixation. Future studies should build on our findings to determine if osteosynthesis of distal clavicular fractures with targeted screw purchase or cortical button placement in the conoid tubercle and intertubercle space increase fixation strength and decreases construct failure. Furthermore, our findings provide consideration for novel distal clavicular locking plate designs with modified screw trajectories or refined surgical techniques with suspensory fixation implants to reliably capture these areas of greatest bone quality.

Reconstruction of the Superior Glenoid Labrum With Biceps Tendon Autograft: A Cadaveric Biomechanical Study.

PURPOSE: To describe 2 superior labral reconstruction techniques using long head of the biceps (LHB) autograft and to investigate the ability of the 2 reconstruction techniques to restore superior restraint to the glenohumeral joint compared with superior labrum-deficient models. METHODS: In this biomechanical study, 10 cadaveric shoulders were cycled on a servohydraulic machine while the force required to cause superior subluxation was recorded. Each specimen was cycled under 4 conditions: intact labrum, SLAP tear, posterior (9- to 12-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 1 [SLR1]), and 180° (9- to 3-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 2 [SLR2]). RESULTS: The mean peak force required to cause superior subluxation in the intact labrum was 32.75 N versus 19.75 N in the SLAP tear (P = .0120). SLR1 required a mean peak force of 31.23 N versus 44.09 N for SLR2 (P = .0175). SLR1 required 94.96% of the force needed in the intact labrum to cause subluxation, whereas SLR2 required 140.6%. SLR1 and SLR2 required 34.21% higher (P = .0074) and 79.84% higher (P = .0033) forces, respectively, to generate subluxation compared with the SLAP tear state. CONCLUSIONS: Both proposed superior labral reconstruction techniques increased the force needed for humeral head superior migration in the setting of a labral tear. SLR1 (posterior labral reconstruction) closely matched the constraint of an intact labrum, whereas SLR2 (180° labral reconstruction) provided greater superior constraint than an intact labrum. CLINICAL RELEVANCE: The natural history of irreparable rotator cuff tears results in superior glenohumeral escape and eventual arthrosis. The superior glenoid labrum is an important contributor to superior glenohumeral constraint and is often degenerated in this setting. Clinical application of the 2 described superior labral reconstruction techniques may improve glenohumeral superior stability in patients with rotator cuff disease and superior labral deficiency.

Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores predict postoperative outcome in total shoulder arthroplasty patients.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has recently been validated in orthopedic patients with upper-extremity disease. The purpose of this study was to describe preoperative and postoperative PROMIS scores in total shoulder arthroplasty (TSA) patients, compare PROMIS physical function (PF) scores with clinical functional measurements, and determine whether preoperative PROMIS scores could predict achievement of the minimal clinically important difference (MCID) postoperatively. METHODS: Preoperative and postoperative (>3 months) PROMIS scores in patients who underwent primary anatomic TSA were reviewed. Preoperative and postoperative shoulder forward flexion and external rotation were also collected. PROMIS PF, pain interference (PI), and depression scores were compared. Accuracy analyses determined whether preoperative PROMIS scores from each domain could predict postoperative achievement of the MCID in the same domain. RESULTS: The study included 62 patients. Significant improvements in PROMIS PF, PI, and depression scores, as well as forward flexion and external rotation, were found postoperatively (P < .001). The multivariate model demonstrated that preoperative PROMIS PF, PI, and depression scores were predictive of postoperative achievement of the MCID (area under the receiver operating characteristic curve, 0.70-0.87). Ninety percent cutoff scores showed that patients with a preoperative PF score lower than 31.7, PI score greater than 66.9, and depression score greater than 55.5 were more likely to achieve the MCID. CONCLUSIONS: In TSA patients, preoperative PROMIS PF, depression, and PI scores demonstrated strong to excellent abilities to predict postoperative achievement of the MCID. PROMIS PF scores were responsive to the functional improvements observed clinically. The reported cutoff scores allow surgeons to identify patients with increased or decreased probabilities of achieving a clinically meaningful improvement after TSA.

Cell-type specific features of circular RNA expression.

Thousands of loci in the human and mouse genomes give rise to circular RNA transcripts; at many of these loci, the predominant RNA isoform is a circle. Using an improved computational approach for circular RNA identification, we found widespread circular RNA expression in Drosophila melanogaster and estimate that in humans, circular RNA may account for 1% as many molecules as poly(A) RNA. Analysis of data from the ENCODE consortium revealed that the repertoire of genes expressing circular RNA, the ratio of circular to linear transcripts for each gene, and even the pattern of splice isoforms of circular RNAs from each gene were cell-type specific. These results suggest that biogenesis of circular RNA is an integral, conserved, and regulated feature of the gene expression program.

Proximal humerus fractures: Postoperative protocols and factors affecting treatment decisions among shoulder and elbow and orthopedic trauma surgeons.

Background: Proximal humerus fractures (PHFs) can lead to functional decline in geriatric and polytraumatized patients. Treatment of PHFs is an area of much debate and much variability between practitioners. Objectives: We surveyed orthopedic trauma (OT) and shoulder and elbow (SE) surgeons to evaluate differences in postoperative protocols when treating acute PHFs with open reduction internal fixation (ORIF), intramedullary nailing (IMN), or hemi or reverse shoulder arthroplasty (rTSA). Materials and methods: We distributed a web-based survey to three OT and SE associations between August 2018-April 2019. Questions included practice characteristics, standard postoperative protocols for weight-bearing, lifting, and range of motion (ROM) by treatment modality, and factors affecting modality and postoperative protocol decisions. We compared the subspecialties. Results: 239 surgeons [100 (42.2 %) OT, 118 (49.8 %) SE] completed the survey. OT were more likely to allow immediate ROM, lifting, and weight bearing following intramedullary nailing (IMN), open reduction internal fixation with a locking plate (ORIF), or arthroplasty (all p < 0.025), and to allow earlier unrestricted use of the extremity following IMN and arthroplasty (p = 0.001, p = 0.021 respectively). OT were more likely to consider operating on a PHF if there was contralateral upper extremity injury or need of the injured arm for work or activities of daily living (all p < 0.026). The subspecialties did not differ significantly on factors affecting their postoperative protocols. OT preferred IMN and SE surgeons preferred rTSA for allowing immediate unrestricted postoperative weight bearing, ROM, or lifting (all p < 0.001). Conclusion: There are significant differences in postoperative protocols between trauma and SE surgeons when treating PHFs. Postoperative protocols should be further studied to balance surgical outcomes and the risks of functional decline when treating patients with PHFs.

Low acromial insufficiency fracture rate in reverse shoulder arthroplasty with distal clavicle excision.

Background: This study investigated the rate of acromial insufficiency fractures (AIF) in patients undergoing reverse shoulder arthroplasty (RSA) with concomitant distal clavicle excision (DCE). Methods: Patients who underwent primary RSA with DCE by a single surgeon from 2010 to 2021 were identified. Exclusion criteria included revision RSA, RSA for fracture, or cases utilizing an augmented baseplate or bone graft. AIF was defined as a radiographically proven acromion or scapular spine fracture. Pain without an identifiable fracture on imaging was defined as an acromial insufficiency reaction. Patient demographics, implant information, and radiograph measurements were compared between patients with and without acromial pathology. Results: One hundred and seventy-five patients were included. Mean age was 72.8 years, and 67% of patients were female. There were 3/174 acromial insufficiency fractures (1.7%). AIF occurred at a mean of 9.3 months after surgery. Twelve patients had insufficiency reactions (6.9%). Patients with acromial pathology were more likely to be female (p = .003) and have a diagnosis of osteoporosis (p = .047) and inflammatory arthritis (p = .049). There was no significant difference between groups in terms of other factors. Conclusion: The AIF rate in patients who underwent RSA with DCE was 1.7%. These findings suggest that DCE in the setting of RSA may have a protective role against AIF.

Quantitative mapping of hemodynamics in the lung, brain, and dorsal window chamber-grown tumors using a novel, automated algorithm.

OBJECTIVE: Hemodynamic properties of vascular beds are of great interest in a variety of clinical and laboratory settings. However, there presently exists no automated, accurate, technically simple method for generating blood velocity maps of complex microvessel networks. METHODS: Here, we present a novel algorithm that addresses the problem of acquiring quantitative maps by applying pixel-by-pixel cross-correlation to video data. Temporal signals at every spatial coordinate are compared with signals at neighboring points, generating a series of correlation maps from which speed and direction are calculated. User-assisted definition of vessel geometries is not required, and sequential data are analyzed automatically, without user bias. RESULTS: Velocity measurements were validated against the dual-slit method and against in vitro capillary flow with known velocities. The algorithm was tested in three different biological models in order to demonstrate its versatility. CONCLUSIONS: The hemodynamic maps presented here demonstrate an accurate, quantitative method of analyzing dynamic vascular systems.

Outcomes of Acute Versus Subacute Scapholunate Ligament Repair.

Purpose: This study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair). Methods: A review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires. Results: The mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups. Conclusions: Although SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis). Type of study/level of evidence: Prognostic III.

Stress resistance and signal fidelity independent of nuclear MAPK function.

Elevated external solute stimulates a conserved MAPK cascade that elicits responses that maintain osmotic balance. The yeast high-osmolarity glycerol (HOG) pathway activates Hog1 MAPK (mammalian ortholog p38alpha/SAPKalpha), which enters the nucleus and induces expression of >50 genes, implying that transcriptional up-regulation is necessary to cope with hyperosmotic stress. Contrary to this expectation, we show here that cells lacking the karyopherin required for Hog1 nuclear import or in which Hog1 is anchored at the plasma membrane (or both) can withstand long-term hyperosmotic challenge by ionic and nonionic solutes without exhibiting the normal change in transcriptional program (comparable with hog1Delta cells), as judged by mRNA hybridization and microarray analysis. For such cells to survive hyperosmotic stress, systematic genetic analysis ruled out the need for any Hog1-dependent transcription factor, the Hog1-activated MAPKAP kinases, or ion, glycerol, and water channels. By contrast, enzymes needed for glycerol production were essential for viability. Thus, control of intracellular glycerol formation by Hog1 is critical for maintenance of osmotic balance but not transcriptional induction of any gene.

Radiographic and clinical outcomes of second generation Trabecular Metal™ glenoid components in total shoulder arthroplasty.

BACKGROUND: Total shoulder arthroplasty with second generation porous tantalum glenoid implants (Trabecular Metal™) has shown good short-term outcomes, but mid-term outcomes are unknown. This study describes the clinical, radiographic, and patient-rated mid-term outcomes of total shoulder arthroplasty utilizing cemented Trabecular Metal™ glenoid components. METHODS: Patients who underwent anatomic total shoulder arthroplasty with cemented Trabecular Metal™ glenoid components for primary osteoarthritis were identified for minimum five-year follow-up. The primary outcome measure was implant survival; secondary outcome measures included patient-rated outcome scores, shoulder range of motion findings, and radiographic analysis. RESULTS: Twenty-seven patients were enrolled in the study. Twenty-one patients had full radiographic follow-up. Mean follow-up was 6.6 years. There was 100% implant survival. Shoulder range of motion significantly improved and the mean American Shoulder and Elbow Society score was 89.8. There was presence of metal debris radiographically in 24% of patients. Twenty-nine percent of patients had evidence of radiolucency. Fourteen percent of patients had moderate superior subluxation. CONCLUSION: Total shoulder arthroplasty with second generation cemented Trabecular Metal™ glenoid components yielded good outcomes at mean 6.6-year follow-up. Metal debris incidence and clinical outcomes were similar to short-term findings. The presence of metal debris did not significantly affect clinical outcomes. Continued observation of these patients will elucidate longer-term implant survival.

A Biomechanical, Cadaveric Evaluation of Single- Versus Double-Row Repair Techniques on Stability of Bony Bankart Lesions.

BACKGROUND: Previous studies comparing stability between single- and double-row arthroscopic bony Bankart repair techniques focused only on the measurements of tensile forces on the bony fragment without re-creating a more physiologic testing environment. PURPOSE: To compare dynamic stability and displacement between single- and double-row arthroscopic repair techniques for acute bony Bankart lesions in a concavity-compression cadaveric model simulating physiologic conditions. STUDY DESIGN: Controlled laboratory study. METHODS: Testing was performed on 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures with a defect width of 25% of the inferior glenoid diameter. Half of the fractures were repaired with a double-row technique, and the contralateral glenoids were repaired with a single-row technique. To determine dynamic biomechanical stability and ultimate step-off of the repairs, a 150-N load and 2000 cycles of internal-external rotation at 1 Hz were applied to specimens to simulate early rehabilitation. Toggle was quantified throughout cycling with a coordinate measuring machine. Three-dimensional spatial measurements were calculated. After cyclic loading, the fracture displacement was measured. RESULTS: The bony Bankart fragment-glenoid initial step-off was found to be significantly greater (P < .001) for the single-row technique (mean, 896 µm; SD, 282 µm) compared with the double-row technique (mean, 436 µm; SD, 313 µm). The motion toggle was found to be significantly greater (P = .017) for the single-row technique (mean, 994 µm; SD, 711 µm) compared with the double-row technique (mean, 408 µm; SD, 384 µm). The ultimate interface displacement was found to be significantly greater (P = .029) for the single-row technique (mean, 1265 µm; SD, 606 µm) compared with the double-row technique (mean, 795 µm; SD, 398 µm). CONCLUSION: Using a concavity-compression glenohumeral cadaveric model, we found that the double-row arthroscopic fixation technique for bony Bankart repair resulted in superior stability and decreased displacement during simulated rehabilitation when compared with the single-row repair technique. CLINICAL RELEVANCE: The findings from this study may help guide surgical decision-making by demonstrating superior biomechanical properties (improved initial step-off, motion toggle, and interface displacement) of the double-row bony Bankart repair technique when compared with single-row fixation. The double-row repair construct demonstrated increased stability of the bony Bankart fragment, which may improve bony Bankart healing.

Chondral Damage After Arthroscopic Repair Techniques for Acute Bony Bankart Lesions: A Biomechanical Study.

BACKGROUND: Bony Bankart lesions can be encountered during treatment of shoulder instability. Current arthroscopic bony Bankart repair techniques involve intra-articular suture placement, but the effect of these repair techniques on the integrity of the humeral head articular surface warrants further investigation. PURPOSE: To quantify the degree of humeral head articular cartilage damage secondary to current arthroscopic bony Bankart repair techniques in a cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Testing was performed in 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures, with a defect width of 25% of the glenoid diameter. Half of the fractures were repaired with a double-row technique, while the contralateral glenoids were repaired with a single-row technique. Samples were subjected to 20,000 cycles of internal-external rotation across a 90° arc at 2 Hz after a compressive load of 750 N, or 90% body weight (whichever was less) was applied to simulate wear. Cartilage defects on the humeral head were quantified through a custom MATLAB script. Mean cartilage cutout differences were analyzed by the Wilcoxon rank-sum test. RESULTS: Both single- and double-row repairs showed macroscopic damage. The histomorphometric analysis demonstrated that the double-row technique resulted in a significantly (P = .036) more chondral damage (mean, 57,489.1 µm2; SD, 61,262.2 µm2) than the single-row repair (mean, 28,763.5 µm2; SD, 24,4990.2 µm2). CONCLUSION: Both single-row and double-row arthroscopic bony Bankart fixation techniques resulted in damage to the humeral head articular cartilage in the concavity-compression model utilized in this study. The double-row fixation technique resulted in a significantly increased cutout to the humeral head cartilage after simulated wear in this cadaveric model. CLINICAL RELEVANCE: This study provides data demonstrating that placement of intra-articular suture during arthroscopic bony Bankart repair techniques may harm the humeral head cartilage. While the double-row repair of bony Bankart lesions is more stable, it results in increased cartilage damage. These findings suggest that alternative, cartilage-sparing arthroscopic techniques for bony Bankart repair should be investigated.

Rotator Cuff Anterior Cable Reconstruction With Long Head of Biceps Tendon Autograft.

Rotator cuff tears with anterior cable disruption show a more detrimental natural history than tears with an intact cable. Anterior cable reconstruction in the setting of such tears provides a potential avenue to improve tissue quality of the repaired construct and enhance repair longevity. Cadaveric studies investigating anterior cable reconstruction have shown biomechanical advantages. We present an arthroscopic surgical technique for rotator cuff anterior cable reconstruction using long head of the biceps tendon autograft in the setting of repairable large-to-massive rotator cuff tears with poor anterior cable tissue quality.

Evaluation and Treatment of Posterior Tibialis Tendon Insufficiency in the Elderly Patients.

INTRODUCTION: Posterior tibialis tendon insufficiency is the most common cause of adult acquired flatfoot deformity in elderly patients. We performed a literature search of primary and secondary journal articles pertaining to posterior tibialis tendon insufficiency in the geriatric population. We examined relevant data from these articles regarding current evaluation in addition to both conservative and advanced treatment approaches that correspond to disease severity. SIGNIFICANCE: There is a paucity of literature to guide treatment of posterior tibialis tendon insufficiency in the elderly, and this condition may be more prevalent in geriatric patients than previously realized. RESULTS: Posterior tibialis tendon insufficiency is an acquired defect that affects 10% of the geriatric population and disproportionately affects women. It is typically caused by degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Conservative treatment with a variety of available ankle braces and non-steroidal anti-inflammatory medications are typically used to treat the first and second stage disease. Surgical repair is warranted for advanced second stage and above posterior tendon insufficiency. A variety of techniques have been proposed, and can include tendon transfer, hindfoot fusion, and even total ankle arthroplasty in extreme cases. CONCLUSION: Posterior tibialis tendon insufficiency causes marked discomfort and alters normal gait biomechanics. Elderly patients typically present with more severe manifestations of the disease. For patients requiring surgery, and especially geriatric patients, the ideal treatment is thought to be a procedure that is minimally invasive in order to maximize positive outcomes for elderly patients. More work is needed to examine clinical and radiographic outcomes of geriatric patients treated for posterior tibialis tendon insufficiency.