Trends in leadership at shoulder and elbow fellowships: a cross-sectional demographic review.

OBJECTIVE: To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs). BACKGROUND: Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery. METHODS: Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history. RESULTS: We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4). CONCLUSION: Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations.

Imbalance in Axial-plane Rotator Cuff Fatty Infiltration in Posteriorly Worn Glenoids in Primary Glenohumeral Osteoarthritis: An MRI-based Study.

BACKGROUND: Fatty infiltration of the rotator cuff evaluated with CT has been associated with asymmetric glenoid wear and humeral head subluxation in patients with glenohumeral arthritis. The relationship between rotator cuff pathologic findings and abnormal glenoid wear plays an important role in determining the optimal surgical management of advanced glenohumeral osteoarthritis. Compared with CT, MRI has increased sensitivity for identifying rotator cuff conditions; therefore, prior studies using CT may have underestimated the association between fatty infiltration of the rotator cuff and abnormal glenoid wear. QUESTIONS/PURPOSES: (1) Compared with Type A glenoids, which muscles in which Walch subtypes have a greater degree of fatty infiltration using Goutallier scores? (2) What glenoid type is associated with greater imbalance in fatty infiltration, as measured by comparing Goutallier scores between the posterior and anterior rotator cuff muscles? (3) What is the correlation between glenoid version and fatty infiltration of the rotator cuff muscles? (4) Comparing Type B2 and B3 glenoids with Type A glenoids, after accounting for age and sex, is there an increase in fatty infiltration of the infraspinatus muscle? METHODS: A total of 129 shoulders from 129 patients undergoing anatomic total shoulder arthroplasty to treat primary glenohumeral osteoarthritis were retrospectively reviewed. Patients had an average age of 66.4 ± 9.3 years and an average BMI of 30.6 ± 6.7 kg/m2, and 53% (69 of 129) were men. All patients underwent MRI within 12 months before total shoulder arthroplasty to assess glenoid morphology and rotator cuff pathologic findings. Three reviewers assessed the images, and glenoid morphology was assigned using the modified Walch classification system (Types A1, A2, B1, B2, B3, C, and D). Fatty infiltration of the rotator cuff was classified using Goutallier scores. The examiners demonstrated moderate-to-good reliability using these classification systems; the Walch classification system had interrater reliability kappa coefficients (κ) from 0.54 to 0.69 and intrarater reliability κ from 0.60 to 0.64. Goutallier scores using the simplified classification system had interrater reliability κ from 0.64 to 0.68 and intrarater reliability κ from 0.64 to 0.79. Thirty-six percent (46 of 129) of the shoulders had posterior wear patterns (18% [23] were Type B2 glenoids; 18% [23] were Type B3 glenoids). The average Goutallier scores for each rotator cuff muscle were determined, and the amount of fatty infiltration was compared between the various Walch subtypes using independent t-tests. Axial-plane imbalance in fatty infiltration of the rotator cuff was assessed by determining the difference in the average fatty infiltration of the posterior rotator cuff muscles (infraspinatus and teres minor) and anterior rotator cuff muscles (subscapularis) and comparing the differences among the Walch subtypes using independent t-tests. The association between glenoid version and fatty infiltration was assessed using Pearson correlations. Finally, a multivariate logistic regression model was used to assess fatty infiltration of the rotator cuff among the various Walch subtypes while accounting for patient age and sex. RESULTS: Compared with Type A1 glenoids, Type B2 and B3 glenoids had an increased amount of fatty infiltration of the infraspinatus (1.6 ± 0.7 versus 0.7 ± 0.4; mean difference 0.9 [95% CI 0.7-1.2]; p < 0.001 and 1.8 ± 0.4 versus 0.7 ± 0.4; mean difference 1.1 [95% CI 0.9-1.4]; p < 0.001, respectively) and teres minor (1.3 ± 0.7 versus 0.6 ± 0.5; mean difference 0.7 [95% CI 0.4-1.0]; p < 0.001 and 1.6 ± 0.6 versus 0.6 ± 0.5; mean difference 1.0 [95% CI 0.7-1.2]; p < 0.001, respectively). There was greater imbalance in fatty infiltration between the posterior and anterior rotator cuff muscles for Type B2 (0.5 ± 0.3) and B3 (0.6 ± 0.5) glenoids than for Type A1 (0.1 ± 0.3) and A2 (0.1 ± 0.6) glenoids (p < 0.001). Only the infraspinatus's fatty infiltration was strongly correlated with glenoid version (r = 0.64; p < 0.001), while fatty infiltration of the other muscles only correlated weakly or moderately. After accounting for age and sex, fatty infiltration in the infraspinatus was associated with Type B2 (OR 66.1 [95% CI 7.6-577.9]; p < 0.001) and Type B3 glenoids (OR 59.5 [95% CI 5.4-661.3]; p < 0.001) compared with Type A glenoids. CONCLUSION: Compared with concentric wear, posteriorly worn glenoids had an imbalance in axial-plane rotator cuff fatty infiltration and an increased amount of fatty infiltration of the infraspinatus and teres minor compared with the subscapularis. These imbalances may contribute to the higher rates of failure after anatomic total shoulder arthroplasty in patients with posterior wear compared with those with concentric wear. Future research should be directed toward investigating the temporal relationship of these findings, as well as understanding the clinical outcomes for patients undergoing anatomic total shoulder arthroplasty who have posteriorly worn glenoids with a high degree of fatty infiltration of the posterior rotator cuff musculature. CLINICAL RELEVANCE: Providers should consider the increased likelihood of higher-grade fatty infiltration of the posterior rotator cuff in the setting of posteriorly worn glenoids, particularly when treating patients without using MRI. These patients have higher rates of failure postoperatively and may benefit from closer monitoring and altered postoperative rehabilitation protocols that target the posterior rotator cuff.

Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA).

BACKGROUND: As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings. METHODS: The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups. RESULTS: Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04). CONCLUSION: Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

Development of 3D method to assess intramuscular spatial distribution of fat infiltration in patients with rotator cuff tear: reliability and concurrent validity.

BACKGROUND: Intramuscular fat infiltration is a critical factor in surgical decision-making and is the most important factor used to prognosticate surgical repair outcomes in patients with rotator cuff tears. Quantitative 3D assessment of total rotator cuff fat infiltration in patients with rotator cuff tears has been realized. However, a reproducible method to evaluate 3D spatial distribution of rotator cuff intramuscular fat has not been established. The objective of this study was to establish the reproducibility, change detectable beyond error, and concurrent validity of a semi-automated method to evaluate the 3D spatial distribution of fat infiltration and muscle volume in patients with rotator cuff tears. METHODS: Thirteen consecutive patients diagnosed with symptomatic rotator cuff pathology and 3.0 T MRI confirmation at a single center were included. Fat-water imaging was used to quantify 3D intramuscular fat (%fat) in sagittal oblique sequences and intramuscular spatial distribution with the semi-automated technique. Each rotator cuff muscle was manually segmented yielding %fat in four axial intramuscular quartile-regions (superior-inferior; Q1-4) and three sagittal (medial/ intermediate/ lateral) regions. Reliability and concurrent validity of %fat and whole muscle volume were calculated with intraclass correlation coefficients (ICC). RESULTS: Intra-rater reliability for intramuscular sagittal divisions (ICC = 0.93-0.99) and axial divisions (ICC = 0.78-0.99) was good/excellent. Inter-rater reliability for %fat (ICC = 0.82-0.99) and volume (ICC = 0.92-0.99) was good/excellent. Concurrent validity with commercialized software showed good/excellent agreement (ICC = 0.66-0.99). CONCLUSIONS: A new semi-automated method to assess 3-dimensional intramuscular distribution of fat infiltration in patients with rotator cuff tears using advanced MR imaging demonstrates high intra and inter-rater reliability and good concurrent validity. Minimal detectable change thresholds established facilitate clinical interpretation for future clinical application of this technique to assess change and treatment efficacy in patients with rotator cuff tears.

Optimizing methods to quantify intramuscular fat in rotator cuff tears with normalization.

OBJECTIVE: To determine which normalization method may best account for confounding individual factors, such as age or BMI, when quantifying fat infiltration on MRI in patients with rotator cuff tears, the effects of normalization using three different muscles (teres major; triceps brachii; teres minor) were compared. METHODS: Thirty-seven consecutive patients diagnosed with rotator cuff pathology were included. MRI fat-water sequences were used to quantify rotator cuff intramuscular fat (%fat). Three reference muscles (teres major, triceps, teres minor) were used to derive normalized %fat. Relationships between intramuscular %fat and tear size, age, and BMI in each rotator cuff muscle, before and after normalization, were compared with Fisher transformations (α = 0.05). RESULTS: Normalization with teres major ameliorated confounding relationships of age and BMI on rotator cuff %fat. In contrast, normalization with triceps maintained the confounding relationships between %fat and age in supraspinatus (p = 0.03) and infraspinatus/teres minor (p = 0.028). Normalization with teres minor maintained the confounding relationship between %fat and BMI in subscapularis (p = 0.039). Normalization with teres major best-maintained relationships between tear size and infraspinatus/teres minor %fat (p = 0.021). In contrast, normalization with triceps or teres minor eliminated all significant relationships with tear size. CONCLUSIONS: Results of this pilot study suggest normalization to teres major using MRI-based %fat quantification methods can effectively control for individual factors, such as BMI or age, and may have utility in evaluating and monitoring rotator cuff fat infiltration attributed specifically to a tendon tear.

Editorial Commentary: Already "Stealth" Organism Propionibacterium acnes Goes Covert by Changing Its Name to Cutibacterium acnes: Shoulder Bacterial Contamination.

Propionibacterium acnes, now Cutibacterium acnes, is found on skin and subcutaneous tissue and is thus hard to eradicate. Infection can result in shoulder pain but be indolent and hard to diagnose; in addition, the organism is difficult to identify requiring long-hold cultures. Despite skin preparation, and second preparation before conversion of arthroscopy to mini-open surgery, we do not yet have a way to effectively eradicate C acnes from deeper dermal layers.

Risk factors for admission after shoulder arthroscopy.

BACKGROUND: Shoulder arthroscopy is a common orthopedic procedure typically performed on an outpatient basis. Occasionally, patients require an unplanned hospital admission. An understanding of the incidence and risk factors for admission after shoulder arthroscopy may assist surgeons in determining which patients may be susceptible to unplanned admission after surgery. METHODS: All consecutive shoulder arthroscopy procedures performed during a 10-year period were reviewed. A 2:1 control-case matching technique was used. Univariate analysis was performed to identify differences between patients admitted after surgery and the control group. Multivariate analysis was performed to identify variables associated with admission. RESULTS: There were 5598 arthroscopic shoulder procedures performed, with 233 patients (4.2%) requiring admission. The most common reason for admission was respiratory monitoring. Risk factors for admission by multivariate analysis were chronic obstructive pulmonary disease (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.51-4.95), diabetes (OR, 2.11; 95% CI, 1.28-3.48), obstructive sleep apnea (OR, 1.90; 95% CI, 1.13-3.21), age (OR, 1.02; 95% CI, 1.01-1.04), body mass index (OR, 1.04; 95% CI, 1.01-1.07), and operative time (OR, 1.01; 95% CI, 1.00-1.01). Regional with monitored anesthesia care decreased risk compared with general anesthesia and regional with general anesthesia (OR, 0.44; 95% CI, 0.30-0.63). CONCLUSION: Chronic obstructive pulmonary disease, obstructive sleep apnea, diabetes, increasing age, increasing body mas index, and increasing operative time were all risk factors for admission after shoulder arthroscopy. The absence of general anesthesia was found to decrease the risk of admission.

The Quality and Accuracy of Online Resources for Total and Reverse Shoulder Replacement.

Recent literature suggests that many online patient resources are poor in quality and lack important clinical information. The purpose of this study was to investigate the value of online resources available to patients considering shoulder arthroplasty. A total of 84 websites were discovered with the terms "total shoulder replacement" (TSR) and "reverse shoulder replacement" (RSR), they were reviewed and graded for quality and accuracy. Overall quality scores were low for TSR and RSR websites, 22.8/45 (95% confidence interval (CI): 19.9-25.6) and 24.2/45 (95% CI: 21.6-26.9), respectively. The authorship of a website significantly influenced the quality for both TSR (p = 0.013) and RSR (p = 0.048). When comparing search rank to quality scores, websites that appeared earlier demonstrated significantly higher quality scores, TSR (p = 0.017) and RSR (p = 0.018). Overall, most websites were accurate but provided incomplete information. Websites authored by professional societies have higher quality scores than websites authored by medical providers or commercial entities. (Journal of Surgical Orthopaedic Advances 28(4):290-294, 2019).

The relationship between the incidence of adhesive capsulitis and hemoglobin A1c.

BACKGROUND: Previous studies have shown no correlation between adhesive capsulitis and hemoglobin A1c (HbA1c). However, HbA1c is only a measure of short-term blood sugar control. We created a previously nonvalidated variable, cumulative HbA1c, that uses HbA1c values over time to estimate the total disease burden a single individual experiences over a period. In this study, we aimed to evaluate whether a correlation exists between cumulative HbA1c levels in diabetic patients and the prevalence of frozen shoulder. We hypothesized that poor long-term glucose control would be correlated with increased incidence of adhesive capsulitis. METHODS: A retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbA1c values were collected. A total of 24,417 patients met the inclusion criteria. A variable was created establishing the cumulative magnitude of abnormal HbA1c values over time, termed "cumulative HbA1c." Logistic regression analysis was performed to determine whether long-term glucose control was predictive of the development of adhesive capsulitis. RESULTS: Cumulative HbA1c was positively associated with adhesive capsulitis (7.6 × 10-5) (ie, odds ratio of 1.000076). The effect size of cumulative HbA1c on adhesive capsulitis was significant; for each unit of time that the HbA1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis. DISCUSSION: Cumulative HbA1c was associated with an increased incidence of adhesive capsulitis. This finding suggests that the effects of diabetes that predispose patients to the development of adhesive capsulitis are dose dependent. Patients with worse blood sugar control over a longer period are at an increased risk of the development of adhesive capsulitis.

Changes in pitching mechanics after ulnar collateral ligament reconstruction in major league baseball pitchers.

BACKGROUND: Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball pitchers. Variations in pitching mechanics before and after UCL reconstructive surgery are not well understood. METHODS: Publicly available pitch tracking data (PITCHf/x) were compared for all Major League Baseball pitchers who underwent UCL reconstruction between 2008 and 2013. Specific parameters analyzed were fastball percentage, release location, velocity, and movement of each pitch type. These data were compared before and after UCL reconstructive surgery and compared with a randomly selected control cohort. RESULTS: There were no statistically significant changes in pitch selection or pitch accuracy after UCL reconstruction, nor was there a decrease in pitch velocity. The average pitch release location for 4-seam and 2-seam fastballs, curveballs, and changeups is more medial after UCL reconstruction (P < .01). Four-seam fastballs and sliders showed decreased horizontal breaking movement after surgery (P < .05), whereas curveballs showed increased downward breaking movement after surgery (P < .05). CONCLUSIONS: Pitch selection, pitch velocity, and pitch accuracy do not significantly change after UCL reconstruction, nor do players who require UCL reconstruction have significantly different pitch selection, velocity, or accuracy than a randomly selected control cohort. Pitch release location is more medial after UCL reconstruction for all pitch types except sliders. Breaking movement of fastballs, sliders, and curveballs changes after UCL reconstruction.

The effect of axillary hair on surgical antisepsis around the shoulder.

BACKGROUND: Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking. METHODS: We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test. RESULTS: There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all). CONCLUSIONS: Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.

Using Pitch-Tracking Data to Identify Risk Factors for Medial Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

Background: Approximately 25% of Major League Baseball (MLB) pitchers undergo medial ulnar collateral ligament reconstruction (UCLR) during their careers. Purpose: To identify risk factors for UCLR that are specific to 2 subgroups of MLB pitchers: right (RHPs)- versus left-handed pitchers (LHPs) and starting (SPs) versus relief pitchers (RPs). Study Design: Case-control study; Level of evidence, 3. Methods: We included 109 MLB pitchers who had undergone UCLR between 2007 and 2019 and had sufficient preinjury data in the 3 years before surgery (T3, T2, T1). A 2:1 matched control cohort was selected for comparison. Pitch velocity, release location, and ball movement were compared between the UCLR and control cohorts in both subgroups in the years before surgery (RHPs vs LHPs and SPs vs RPs). Binary logistic regression was used to identify independent risk factors for UCLR. Results: The mean horizontal release location for the UCLR group was 5.8 cm more lateral than for the control group (P = .028). For all pitchers, every 2.5-cm lateral shift in release location in the years leading up to UCLR equated to a 3.7% increase in the odds of UCLR. For RPs, this risk was more substantial: a 5.8% increase in odds per 2.5 cm. SPs in the UCLR group demonstrated significantly different T1 horizontal release locations compared with SPs in the control group, though not to a statistically significant change over the 3 years before surgery. However, in the 3 years before surgery, the horizontal release location for RPs in the UCLR group moved 2.1 cm more lateral, as compared with 2.7 cm more medial for RPs in the control group (P = .007). For LHPs, a decrease in mean pitch velocity by 1 mph (1.6 km/h) in the years leading up to surgery increased the odds of UCLR by 45%. Conclusion: Increasing lateralization of release point in the years before surgery increased the risk of UCLR, specifically for relievers. Our findings add to the growing body of evidence that release location is an important variable in analyzing the risk of UCLR in MLB and that risk stratification may be dependent on pitcher characteristics such as position, handedness, and weight.

Biologic and pharmacologic augmentation of rotator cuff repairs.

As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. Histologic studies have shown that restoration of the rotator cuff footprint during repair can help reestablish the enthesis. In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.

Infection after shoulder surgery.

Infection after shoulder surgery is rare but potentially devastating. Normal skin flora, including Staphylococcus aureus, Staphylococcus epidermidis, and Propionibacterium acnes, are the most commonly isolated pathogens. Perioperative measures to prevent infection are of paramount importance, and clinical acumen is necessary for diagnosis. Superficial infections may be managed with local wound measures and antibiotics; deep infections require surgical débridement in combination with antibiotic treatment. Treating physicians must make difficult decisions regarding antibiotic duration and the elimination of the offending organisms by resection arthroplasty, direct implant exchange, or staged revision arthroplasty. Eradication of a deep infection is usually successful, but the course of treatment is often protracted, and tissue destruction and scar may adversely affect functional outcome.

A reproducible and practical method for documenting the position of the humeral head center relative to the scapula on standardized plain radiographs.

BACKGROUND: Recent articles in this journal showed the clinical importance of the position of the humeral head center in relation to the glenoid. However, the precision, reproducibility, and sensitivity of this and other methods of documenting the head center position have not been evaluated in detail. MATERIALS AND METHODS: We used templates to fit a coordinate system to the scapular anatomy visible on standardized radiographs. Two observers then used these templates to measure the position of the head center relative to this coordinate system on 25 normal shoulder radiographs and on 25 radiographs of shoulders with cuff tear arthropathy (CTA). RESULTS: Head center measurements had excellent precision. Normal shoulder radiographs showed a consistent head center position (0.7 ± 1.7 mm medial and 0.6 ± 1.3 mm inferior to the coordinate origin on the anteroposterior view and 0.1 ± 1.3 mm medial and 0.0 ± 1.3 mm anterior to the coordinate origin on the axillary view). The head center of CTA shoulder radiographs was 10.18 ± 5.16 mm above the coordinate origin on the anteroposterior view, significantly different from that for the normal shoulder radiographs (P < .001). DISCUSSION: The relative position of the humeral head center to the scapula determines the resting length and the moment arms of the scapulohumeral muscles. Correlation of shoulder function with the head center position may provide insights into both shoulder pathomechanics and the optimization of shoulder arthroplasty. CONCLUSION: This practical technique showed a high degree of precision and reproducibility for normal and CTA shoulder radiographs as well as a high level of discrimination between these two groups.

Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery.

HYPOTHESIS: Deep infection after shoulder surgery is a rare but devastating problem. This study tested the hypothesis that the home application of a 2% chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a standard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder. MATERIALS AND METHODS: This randomized, prospective study evaluated 100 consecutive patients undergoing shoulder surgery. Patients were randomly assigned to use 2% chlorhexidine gluconate-impregnated cloths (treatment group) or to shower with soap and water before surgery (control group). Cutaneous cultures were taken from the patients'shoulders in the preoperative holding area. Patients were monitored for 2 months postoperatively for clinical signs of infection. RESULTS: In the treatment group vs the control group, the overall positive culture rate was 66% vs 94% (P = .0008), and the positive culture rate for coagulase-negative Staphylococcus was 30% vs 70% (P = .0001). The positive culture rate for Propionibacterium acnes was 46% in the treatment group vs 58% in the control group (P = .32). No infections occurred in any patients at a minimum of 2-months after surgery. DISCUSSION: The use of the 2% chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus, a known causative agent of postoperative shoulder infections. CONCLUSION: Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies.

Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less.

BACKGROUND: Glenohumeral arthritis in younger individuals is challenging because of the complex pathology, need for extended durability, and high expectations of the patients. Humeral hemiarthroplasty combined with concentric glenoid reaming is a surgical option for the management of glenohumeral arthritis that avoids the risks of glenoid component failure and avoids the challenges of tissue interposition. The results of this procedure in young patients have not been previously reported. METHODS: Sixty-five shoulders in patients who were 55 years old or less at the time of surgery underwent humeral hemiarthroplasty combined with concentric glenoid reaming and were followed for a minimum of 2 years or until the time of revision surgery. Patient self-assessments of shoulder comfort and function were compared before and after surgery. For 22 of these shoulders, standardized radiographs were available for follow-up evaluation. RESULTS: Nine shoulders required revision surgery. These shoulders had 3 ± 3 prior surgeries, in comparison to 1 ± 1 prior surgeries for the unrevised group. For the 56 unrevised shoulders, the number of Simple Shoulder Test functions that could be performed improved from a mean of 4.1 before surgery to a mean of 9.5 at an average follow-up of 43 months (range, 24-85) (P < .001). For the 22 shoulders with radiographic follow-up, medial glenoid erosion averaged 1.1 mm (range, 0.0-6.3 mm) at an average of 44 months after the procedure. CONCLUSION: In selected patients 55 years or younger with glenohumeral arthritis, this procedure can provide significant improvement in self-assessed shoulder comfort and function.

A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming.

HYPOTHESIS: Glenoid erosion and medial migration of the humeral head prosthesis have been observed after most types of shoulder arthroplasty. A method of measuring the change in humeral head position with time after shoulder prosthetic arthroplasty was applied it to 14 shoulders that underwent humeral hemiarthroplasty with concentric glenoid reaming. We hypothesized that the measurement technique would be reproducible and that the rate of wear would be small in the series of shoulders studied. MATERIALS AND METHODS: Standardized anteroposterior and axillary radiographs were obtained after surgery. Two examiners measured the position of the humeral head center in relation to scapular reference coordinates for the anteroposterior and axillary projections and plotted these values against time after surgery. The change in position was characterized as the slope of this plot. Shoulders were included if there were at least 3 sets of postoperative films, the last being at least 2 years after surgery. RESULTS: The slopes measured by the 2 examiners agreed within 0.5 mm/y for the anteroposterior and the axillary projections. For the series of shoulder arthroplasties, the rate of movement of the head center toward the scapula was less than 0.4 mm/y for either examiner in either projection. DISCUSSION: Medial migration is a concern after any type of shoulder arthroplasty, whether a hemiarthroplasty, a biological interpositional arthroplasty, or a total shoulder arthroplasty. Quantifying the rate of medial migration over time after shoulder arthroplasty is an important element of clinical follow-up. CONCLUSIONS: This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. The average rate of medial migration in the shoulders in this study was small.

Clinical Y-view versus 3-dimensional assessments of intramuscular fat in patients with full-thickness rotator cuff tears.

RATIONALE AND OBJECTIVES: Recent evidence suggests an inhomogeneous distribution of intramuscular rotator cuff fat infiltration (FI) in a small sample of individuals with rotator cuff tears, yet clinically just a few slices at the scapular Y-view are used to evaluate FI in patients with rotator cuff tears. The purpose of this study was to determine if assessment of FI using the scapular Y-view is representative of the entire muscle in patients with full-thickness rotator cuff tears, and whether this varies by tear size. MATERIALS AND METHODS: Patients (N = 25) diagnosed with full-thickness rotator cuff tear and confirmed with magnetic resonance imaging (MRI) were included. Fat-water sequences were used to objectively quantify mean FI (%) in the entire 3D muscle and the mean from 3 slices at the Y-view. Mixed-model 2 × 2 ANOVAs were used to assess for differences between methods, and if results vary by tear-size. RESULTS: There were no statistically significant differences between mean amount of FI of the entire 3D muscle and mean Y-view in the supraspinatus or infraspinatus muscles (p > 0.05). Additionally, this did not differ across tear size groups (p > 0.05). CONCLUSION: Results of this study suggest FI assessed in the Y-view is not different (mean difference < 1.0%) from FI of the entire 3D muscle in patients with full-thickness rotator cuff tears. Therefore, the clinical utility of evaluating rotator cuff intramuscular fat infiltration with the Y-view is further supported in patients with full-thickness rotator cuff tears across tear sizes.

Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure.

¼: Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). ¼: The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. ¼: During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. ¼: The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. ¼: While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. ¼: Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.