The Effect of Primary ACL Reconstruction on Career Longevity in English Premier League and Championship Soccer Players Compared With Uninjured Controls: A Matched Cohort Analysis.

BACKGROUND: Because of the multitude of variables that affect the retirement decisions of professional soccer players, it has proven difficult to isolate the effect of undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) on career longevity. PURPOSE: To compare the career longevity of professional soccer players after a primary ACLR with that of an uninjured matched control cohort. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a consecutive series of primary ACLR was performed between 2008 and 2018 in professional male soccer players from the senior author's practice. Each athlete with ACLR was matched to 3 control athletes who had not undergone ACLR according to age, league, playing position, and preinjury game appearances/minutes played. Player career statistics-including league, game appearances, and game minutes-were compiled for each year until retirement or July 1, 2022. RESULTS: A total of 82 soccer players in the English Premier League or Championship at the time of their primary ACLR were matched to 246 control athletes. The mean career length after ACLR was 6 ± 2.6 years, while that of the matched control athletes was 7.6 ± 2.8 years (P < .001). After primary ACLR, an athlete had a 2 times greater chance of retirement compared with the matched control athlete (hazard ratio, 2.19; P < .001). At 5 years after ACLR, 16% of athletes had retired from professional soccer, while 8.5% of the matched cohort were retired (P = .060). By 10 years, 72% of the ACLR cohort had retired compared with 43% of the matched cohort (P < .001). Forwards were more likely to have shortened careers compared with goalkeepers (P = .021); however, no significant differences were observed between midfielders, defenders, and forwards. Within the ACLR cohort, a contralateral ACL tear during the athlete's career caused a 2.30 times (P = .022) increased chance of retirement compared with athletes with only 1 ACL tear during their career. Mechanism of injury, meniscal pathology, graft rerupture, and chondral lesions did not affect career length. CONCLUSION: Professional male soccer players who underwent ACLR had decreased career length by approximately 1.6 years compared with a matched player cohort.

Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not.

BACKGROUND: Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. PURPOSE: To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. STUDY DESIGN: Controlled laboratory study. METHODS: Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. RESULTS: sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. CONCLUSION: In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. CLINICAL RELEVANCE: In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

Determinants of Performance in Professional Soccer Players at 2 and 5 Years After ACL Reconstruction.

BACKGROUND: A number of studies have investigated return to play after anterior cruciate ligament reconstruction (ACLR) in professional soccer players, but it is unclear which factors are associated with a return to the preinjury performance and ability to play over time. PURPOSE: To identify factors that contribute to a professional soccer player's return to preinjury performance after ACLR, as well as to report their playing performance at 2 and 5 years after ACLR compared with their preinjury performance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A consecutive cohort of professional soccer players undergoing primary ACLR were analyzed between 2005 and 2019. A minimum 2-year follow-up was required. The effect of patient, surgical, and postoperative factors on performance rates, defined as a combination of league level and playing time, was evaluated with univariate and multivariate logistic regression models. RESULTS: A total of 200 male professional soccer players were included. When combining league level and playing time, 30% of athletes returned to their preinjury performance at 2 years and 22% at 5 years. However, 53% of athletes returned to their preinjury performance for at least 1 season by year 5. At 2 years, a chondral lesion of grade 3 or 4 decreased the odds of return to preinjury performance (odds ratio [OR], 0.37; P = .010). Athletes receiving an ACLR with the addition of a lateral extra-articular tenodesis procedure were 2.42 times more likely to return to preinjury performance at 2 years than athletes with ACLR alone (P = .004). By 5 years after ACLR, athletes aged ≥25 years at the time of reconstruction were 3 times less likely to be performing at their preinjury performance (OR, 0.32; P < .001), and those with a grade ≥3 chondral lesion were >2 times less likely to be performing at their preinjury performance (OR, 0.43; P = .033). CONCLUSION: The presence of >50% thickness chondral pathology, ACLR without lateral extra-articular tenodesis, and age >25 years at the time of surgery were all significant risk factors of worse performance rates after ACLR. Significant decreases in performance rates were noted at 2 and 5 years postoperatively.

A "Short Isometric Construct" Reconstruction Technique for the Medial Collateral Ligament of the Knee.

Recently there has been increased focus on the medial collateral ligament (MCL) and the role the medial ligament complex plays in preventing valgus and external rotation, especially in the setting of a combined ligament injury. Multiple surgical techniques purport to reproduce "normal anatomy"; however, only one technique addresses the deep MCL fibers and the prevention of external rotation. Thus we describe the "short isometric construct" MCL reconstruction which is stiffer than the anatomic reconstructions. The "short isometric construct" technique resists valgus throughout range of motion whereas its obliquity resists tibial external rotation, helping to reduce the risk of anterior cruciate ligament graft re-rupture.

A Comparison of All-inside and Inside-out Meniscal Repair in Elite Athletes.

BACKGROUND: The popularization of all-inside (AI) meniscal repair devices has led to a shift away from the historical gold standard of inside-out (IO) meniscal repair without comparative studies to support the change. PURPOSE: To compare the failure rate and time to failure of AI and IO meniscal repair performed in elite athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed of all professional and national- and international-level amateur athletes who underwent meniscal repair, with a minimum of 2-year follow-up between January 2013 and September 2019. Meniscal repair was classified as AI or IO depending on the surgical technique performed. Treatment failure was defined as patients having to undergo subsequent surgery to address a persistent meniscal tear after repair. Cox proportional hazards modeling was used to determine if meniscal repair failure rates differed by the location and technique of meniscal repair. Models were controlled for known risk factors such as age, sex, sport, and concurrent cruciate ligament reconstruction. RESULTS: A total of 192 (135 lateral and 57 medial) meniscal repairs were performed in elite athletes during the study period. Overall, 41 (21%) meniscal repairs met the criteria for failure. Medial meniscal tears repaired with the AI technique failed at a significantly higher rate (18/31 [58%]) than medial meniscal tears repaired with the IO technique (6/26 [23%]) or lateral meniscal tears repaired with the AI (9/76 [12%]) or IO (8/59 [14%]) technique (P < .001). Cox proportional hazards modeling revealed that a medial meniscal tear repaired with the AI technique had an almost 8 times greater hazard of failure than a lateral meniscal tear repaired with the AI technique (P < .001). At 1 year postoperatively, 8% of lateral meniscal repairs had failed (regardless of technique), while medial meniscal tears failed at a rate of 16% with the IO technique and 42% with the AI technique. By 2 years, 53% of medial meniscal tears repaired with the AI technique had failed, and by 5 years, 63% had failed. CONCLUSION: AI repair of medial meniscal tears led to a higher rate of failure than IO repair of medial or lateral meniscal tears in elite athletes. Medial meniscal repair failed at a higher rate than lateral meniscal repair.

Quadriceps Strain and TKA: Contribution of the Tourniquet and Intramedullary Rod to Postoperative Thigh Pain: A Randomized Controlled Trial.

BACKGROUND: Thigh pain is relatively common after total knee arthroplasty (TKA) and has been attributed to compression of the thigh muscles by the tourniquet used during surgery. Thigh pain that occurs after a TKA that was performed without a tourniquet may be due to a strain of the quadriceps muscle or insertion of the intramedullary (IM) rod. The purpose of the present study was to determine the cause of thigh pain after TKA in a randomized controlled trial evaluating tourniquet use, IM rod use, and quadriceps strain. METHODS: This prospective randomized controlled trial enrolled 97 subjects undergoing primary knee arthroplasty into 4 groups according to tourniquet use (yes or no) and IM rod use (yes or no). Quadriceps strain was evaluated with magnetic resonance imaging (MRI) on postoperative day 1 (POD 1). Data collected preoperatively, intraoperatively, and postoperatively until the 6-week clinical visit included pain levels for the knee and thigh (recorded separately) and knee range of motion. RESULTS: Regardless of tourniquet or IM rod use, 73 (75%) of the 97 patients reported thigh pain on POD 1. Thigh pain at 2 weeks postoperatively was indicative of a quadriceps strain. Use of a tourniquet and patient-reported thigh pain at 2 weeks increased the odds of a quadriceps strain, whereas IM rod use did not significantly contribute to thigh pain. CONCLUSIONS: The etiology of thigh pain after TKA may be multifactorial; however, an iatrogenic quadriceps strain is one source of thigh pain after TKA, especially if the pain persists 2 weeks after surgery. LEVEL OF EVIDENCE: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

Determination of rotator cuff tear reparability: an ultrasound-based investigation.

Background: The use of ultrasound as a viable diagnostic tool for routine office visit evaluation of rotator cuff integrity is slowly gaining acceptance in orthopedic practice. However, the reliability of accurately assessing rotator cuff tear reparability by ultrasound has limited evidence in the literature. The purpose of this study was to compare preoperative assessment of cuff tear reparability via ultrasound with the arthroscopic determination of reparability at the time of surgery. Methods: We prospectively collected preoperative ultrasound and arthroscopic imaging data on 145 patients (80 or 55% men and average age of 60.7 years) who underwent arthroscopic posterior superior rotator cuff repair. Three independent experienced orthopedic surgeons retrospectively reviewed all ultrasound studies and arthroscopic imaging and determined if the posterior superior rotator cuff tendon edge was able to be viewed via ultrasound and determined with the arthroscopic images if the tear was reparable. Results: On review of the ultrasound and arthroscopic data, if the edge of the rotator cuff tendon was able to be viewed on the coronal ultrasound image, it was most likely reparable with a positive predictive value of 97.6% and a positive likelihood ratio of 5.8. Sensitivity was 84.4%, and specificity was 76.9%. The negative predictive value was 37.5%, and the negative likelihood ratio was 0.17. The interobserver reliability was 0.63, and the observers were unanimous in determining the tendon edge was able to be visualized in 99 of 145 cases (68%). Conclusion: Preoperative ultrasound evaluation of the shoulder for posterior superior rotator cuff tears is a useful tool for assessing rotator cuff integrity and may help predict intraoperative reparability of the tendon. This study demonstrates that if the cuff tear edge is able to be visualized, there is a high probability of successful arthroscopic restoration of the tendon to its native attachment. Conversely, if the tear edge is unable to be visualized, there is a moderate chance of the tear being irreparable. These results help expand the knowledge base of the usefulness of in-office ultrasound performed by the surgeon in predicting the results of surgical intervention for rotator cuff tears.

Rebranding the 'anatomic' ACL reconstruction: Current concepts.

The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.

Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes.

BACKGROUND: There is growing evidence that anterolateral procedures can reduce the risk of rerupture in high-risk recreational athletes undergoing primary anterior cruciate ligament (ACL) reconstruction (ACLR). However, this effectiveness has never been evaluated in elite athletes. PURPOSE: The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis (LET) in reducing revision rates in primary ACLR in elite athletes. Additionally, this study evaluated whether LET had a greater effect when combined with ACLR utilizing a hamstring or patellar tendon graft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive cohort of elite athletes with an isolated ACL tear undergoing autograft patellar or hamstring tendon reconstruction with or without Lemaire LET were analyzed between 2005 and 2018. A minimum 2-year follow-up was required. The association between the use of LET and ACL graft failure as defined by revision ACLR was evaluated with univariate and multivariate logistic regression models. RESULTS: A total of 455 elite athletes (83% men and overall age 22.5 ± 4.7 years) underwent primary ACLR with (n = 117) or without (n = 338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure, including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACLR reduced the risk of graft failure by 2.8 times, with 16.5 athletes needing LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (relative risk = 0.325; P = .029) as compared with ACLR alone after controlling for sex and age at ACLR. Including graft type in the model did not significantly change the risk profile, and although a patellar tendon graft had a slightly lower risk of failure, this was not statistically significant (P = .466). CONCLUSION: The addition of LET reduced the risk of undergoing revision by 2.8 times in elite athletes undergoing primary ACLR. This risk reduction did not differ significantly between the patellar tendon and hamstring tendon autografts. With these results, status as an elite athlete should be included in the indications for a LET, as they are at increased risk for ACL graft failure.

Patient satisfaction and clinical outcomes of reverse shoulder arthroplasty: a minimum of 10 years' follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has been shown to reliably improve pain and functional outcomes for multiple pathologies. Despite its increasing use in the United States since its introduction in 2004, few studies have investigated long-term outcomes of this procedure. This information is vital in many ways, including durability of functional outcomes, complication profiles, and implant survivorship. METHODS: Our prospectively collected shoulder arthroplasty registry included 471 patients who had undergone RSA prior to December 31, 2010, by a single surgeon at a high-volume shoulder arthroplasty center. The study sample included 94 patients with a minimum of 10 years' follow-up, and we evaluated the indications for RSA, complications, pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction on these patients at baseline, 2-5 years, and 10 or more years of follow-up. Prosthesis survivorship was determined by Kaplan-Meier survival analysis performed with revision for any reason as the end point for all 471 patients in the study period regardless of follow-up interval. RESULTS: The 93 patients with at least 10 years of follow-up were 63% female (60) and 37% male (34), with an average age of 66±10 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs. Patient-reported outcome measures at 10 years or more included a current pain rating averaging 2±3 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73±28. There was no deterioration in function or pain from midterm to long-term follow-up, as the SANE and pain score changed by less than the minimal clinically important difference or improved in 87% and 90% of patients, respectively. Overall, patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied. For the subset of 68 patients who were contacted for follow-up, 64 (94%) would have the procedure again and 4 (6%) would not. Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% (95% confidence interval [CI] 84%-92%) at 5 years and 81% (95% CI 74%-86%) at 10 years. CONCLUSIONS: This study presents the largest American cohort of Grammont design RSA at a minimum 10-year follow-up. Although RSA provided clinically significant and durable improvements in pain and function, the complication and revision rates were higher than prior reports. Despite this, the vast majority of patients were satisfied and would have the procedure again.

Early Complication Rates Following Total Shoulder Arthroplasty for Instability Arthropathy With a Prior Coracoid Transfer Procedure.

The purpose of this study was to report early complications for anatomic total shoulder arthroplasty (aTSA) performed for instability arthropathy after a prior coracoid transfer procedure and compare them with those of a control group of patients following aTSA for primary osteoarthritis. A retrospective review was performed of 14 patients after aTSA with a prior coracoid transfer procedure. A control group of 42 patients with an aTSA for primary osteoarthritis were matched 3:1 according to age, sex, body mass index, comorbidities, and dominant shoulder. Chart reviews identified any complications within 1 year, in addition to blood loss and operative time in both groups. Preoperative computed tomography scans were used to determine Walch glenoid classification and Goutallier classification of the subscapularis. The mean operative time was not significantly different between the coracoid transfer cohort and the control group, and the mean estimated blood loss was only 6.9 mL greater in the coracoid transfer group. The coracoid transfer group had 2 (14.3%) patients with complications, with 1 early revision for an acute deep infection. The control group had 4 (9.5%) complications in 3 (7.1%) patients, with no early revisions. There was no statistical difference in complications between the groups (P=.618). Anatomic TSA for instability arthropathy after coracoid transfer had similar operative time, blood loss, and 1-year complication rates as those of the control group. These results provide some evidence to support the continued use of aTSA in select patients with instability arthropathy after prior coracoid transfer procedure. [Orthopedics. 2021;44(4):e482-e486.].

Trauma fellowship impact on trends and complications of operatively treated clavicle fractures in recently trained orthopedic surgeons.

PURPOSE: The purpose of this study was to evaluate whether fellowship training affected trends and complications of operative clavicle fracture treatment in newly trained orthopedic surgeons. METHODS: The American Board of Orthopedic Surgery (ABOS) database was utilized to identify cases of open treatment of clavicle fractures submitted by ABOS Part-II Board Certification candidates. From 2005 to 2017, 3148 candidates performed at least one open clavicle fracture treatment. Overall, 6919 cases were included; 3516 of these had over 6 weeks of follow-up. Candidates were divided by fellowship type into 5 groups: Trauma, Sports Medicine, Hand and Upper Extremity or Shoulder, multiple, and other or no fellowship(s). Group differences were analyzed with ANOVA and Bonferroni post hoc analysis. Complications, reoperations, nonunion rates, and readmissions between groups were evaluated with Chi-squared test and logistic regression analyses. RESULTS: Case volume during the study period was significantly higher after 2007. Trauma candidates performed significantly more operations for clavicle fracture per candidate while candidates with other or no fellowship(s) performed significantly fewer operations per candidate. Patients treated by Trauma candidates were significantly older, had significantly fewer early surgical complications and significantly more early medical complications. Nonunion rates were not significantly different between groups. CONCLUSION: Candidates treated clavicle fractures surgically more often in 2007 and beyond. Trauma candidates treated older patients, had fewer early surgical complications, and had more medical complications. Reoperation, readmission and nonunion rates were not significantly different between groups.

Mortality After Revision Total Hip Arthroplasty.

BACKGROUND: In counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA. METHODS: An institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision. RESULTS: The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate. CONCLUSION: The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.

Efficacy of PRECICE Nail in Treatment of Adult Patients With Posttraumatic Femoral Leg Length Discrepancy.

SUMMARY: Posttraumatic, limb length discrepancy in adults is a challenge to treat, and multiple treatment protocols over the years have shown varying levels of success and complications. Before the introduction of the PRECICE nail in 2011, our preferred method of limb lengthening used an Ilizarov or Taylor Spatial frame. To assess the PRECICE nail, we evaluated the accuracy and complications during treatment in a series of skeletally mature patients with posttraumatic femoral limb length discrepancy. The surgical technique along with a case series of 8 patients are described in detail. On average, the target lengthening for the PRECICE nail was 44 mm, and all patients achieved lengthening within 2 mm and complete bony consolidation. The only observed complication in our series was a broken screw 1 year after the patient started weight-bearing. The PRECICE nail demonstrated promising results and was useful for bone regeneration and consolidation without the need for additional procedures. The rate of complications was low compared with previous methods, making this device an excellent treatment option.

A localized laminar flow device decreases airborne particulates during shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room-mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs). METHODS: Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups. RESULTS: A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P = .53) and the average staff count (P = .16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (ß = -0.583, P < .001) along with surgical time and particulates with a diameter ≥ 5 µm. Staff count and particulates with a diameter < 5 µm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients. DISCUSSION: This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding-specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty.

Early to midterm outcomes of anatomic shoulder arthroplasty performed on dysplastic glenoids.

BACKGROUND: Treatment of primary osteoarthritis with glenoid dysplasia or Walch type C glenoids remains controversial. There is scant literature available on patient outcomes after anatomic shoulder arthroplasty in patients with Walch type C glenoids. The purpose of this study was to evaluate the outcomes of total shoulder arthroplasty (TSA) for Walch type C dysplastic glenoids with standard (nonaugmented) glenoid components compared with TSA for glenoids with concentric wear and minimal erosion (Walch type A1). We hypothesized that TSA performed for Walch type C dysplastic glenoids with standard glenoid components can reliably produce successful results at short- to midterm follow-up. METHODS: We identified all patients who had primary anatomic TSA performed for osteoarthritis in a prospective shoulder arthroplasty registry collected from 2004 to the present time. Twenty-nine patients met inclusion criteria of a preoperative Walch type C dysplastic glenoid, treatment with TSA using standard (nonaugmented) glenoid components, and a minimum of 2-year clinical follow-up. A matched cohort of 58 patients with a type A1 glenoid and minimum of 2-year clinical follow-up for anatomic shoulder arthroplasty served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), patient satisfaction, complications, and revisions were evaluated in both cohorts. RESULTS: The mean follow-up for this study was 4.5 years (standard deviation, 2.6 years; range, 2-10 years). Baseline measures were not significantly different between the Walch type C dysplastic group and the matched type A1 cohort (all P > .05). Both groups showed significant improvements in ASES, ASES pain, and SANE scores from baseline to the final follow-up (all P < .001). The Walch type C group had no significant differences in ASES score (P = .118), ASES pain (P = .730), or SANE score (P = .168) compared with the matched type A1 cohort. The complication rate of patients with a type C glenoid was 14% (4 of 29) with a 7% (2 of 29) revision rate. Similarly, the complication rate for the A1 matched cohort was 17% (10 of 58) with a 12% (7 of 58) revision rate. Both groups had high patient satisfaction without statistical differences (P = .549). In addition, there were no differences in the rate of radiographic lucencies or Lazarus scores (P = .222). CONCLUSIONS: Anatomic TSA reliably produced clinically significant improvements in pain and function and similar short- to midterm outcomes in patients with Walch type C dysplastic glenoids compared with patients with type A1 glenoids. Anatomic TSA with standard (nonaugmented) glenoid components should remain an option in patients with Walch type C dysplastic glenoids despite emerging treatment options including augmented glenoid components and reverse TSA.

Anatomic and reverse shoulder arthroplasty in patients 70 years of age and older: a comparison cohort at early to midterm follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has gained popularity in elderly patients because of its limited reliance on rotator cuff function and high survivorship rates. However, although there are theoretical advantages of RSA over anatomic total shoulder arthroplasty (TSA) in elderly patients, there is little data to guide surgeons on implant selection in this population. METHODS: Patients were identified from our prospectively collected shoulder arthroplasty registry. We included patients between the age of 50 and 89 years who underwent primary TSA for osteoarthritis with intact rotator cuff or primary RSA for cuff tear arthropathy. The minimum and mean clinical follow-up was 2 and 3.1±1.3 years, respectively. Four patient groups were formed for analysis: (1) TSA age 50-69 years (n=274), (2) TSA age 70-89 years (n=208), (3) RSA age 50-69 years (n=81), and (4) RSA age 70-89 years (n=104). We evaluated age group differences in pain, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient satisfaction, complications, and revisions. RESULTS: All groups showed significant improvements from preoperative to final follow-up for all outcome measures (P < .001). Visual analog scale for pain average score decreased from 5.8 preoperatively to 1.1, with no significant differences between groups (TSA P = .180; RSA P = .103). Final ASES scores and improvement from preoperative ASES score between the age groups were not significantly different (TSA P = .520; RSA P = .065). There were no significant differences in outcomes between TSA in patients older than 70 years vs. patients younger than 70 years (all P > .05); however, older RSA patients reported better function during activities of daily living (P = .020) than their younger counterparts. Patients undergoing TSA had a lower revision rate of 3.9% compared with 8.1% in the RSA group (P = .043). CONCLUSIONS: TSA and RSA are reliable procedures for patients older than 70 years, and have comparable results to their respective patient cohorts younger than 70 years. Although some surgeons anecdotally advocate for RSA in patients older than 70 years with primary osteoarthritis and an intact rotator cuff, we found no difference in outcomes for TSA based on our age cutoff. Given satisfactory results following TSA in patients 70 years of age and older, we do not routinely perform RSA for primary osteoarthritis with an intact rotator cuff solely based on age. Further studies and longer follow-up are needed to determine the optimal implant selection for elderly patients with primary osteoarthritis.

Outcomes of anatomic shoulder arthroplasty performed on B2 vs. A1 type glenoids.

BACKGROUND: Glenoid component malpositioning and glenoid component retroversion have been associated with higher rates of radiolucencies, raising concerns about its implications on glenoid loosening and ultimate failure of anatomic total shoulder arthroplasty (TSA). Although there is literature regarding the relative advantages of techniques to address posterior glenoid bone loss, we are not aware of studies comparing outcomes of TSA on these challenging Walch type B2 glenoids vs. more common A1 glenoids. The purpose of this study is to compare outcomes of TSA performed on A1 glenoids and B2 glenoids treated with asymmetric glenoid reaming. METHODS: We identified 1045 shoulders that had primary TSAs performed for osteoarthritis in a prospective shoulder arthroplasty registry. Two hundred eighty-nine shoulders met inclusion criteria of a preoperative Walch type A1 (178) or B2 (111) glenoid morphology, treatment with TSA, asymmetric reaming in the B2 group, and a minimum of 2-year clinical and radiographic follow-up. Postoperative radiographs were assessed for lucencies, and patient-reported outcome measures were collected at all follow-up visits. RESULTS: Follow-up averaged 40 ± 15 months for all patients, and more men presented with a B2 glenoid (80 of 111; 72%) compared with A1 (101 of 178; 57%) (P = .009). Age at surgery (P = .166), dominant-sided surgery (P = .281), body mass index (P = .501), smoking (P = .155), preoperative opioid use (P = .154), and diabetes (P = .331) were not significantly different between groups. Both groups had similar Constant Strength scores preoperatively (A1: 4.7 ± 7.1, and B2: 4.3 ± 7.3) but the B2 group improved significantly more at final follow-up (A1: 10.3 ± 6.2 vs. B2: 12.7 ± 6.7, P = .005). The Total Constant score was also significantly better at follow-up in the B2 glenoid group (P = .039). All other Constant subscales, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) measures showed significant improvement preoperatively to final follow-up (all P <.001) but there were no significant differences between the A1 and B2 glenoid groups (all P > .05). A similar proportion of patients rated their satisfaction as either very satisfied or satisfied between the A1 (160; 90%) and B2 (100; 90%) (P = .613). Lazarus scores were also similar between the A1 and B2 groups (P = .952) as were the rates of humeral radiolucent lines (P = .749) and humeral osteolysis (P = .507). CONCLUSIONS: Although patients with B2 glenoids may present a more technically challenging anatomic total shoulder arthroplasty, treatment with concurrent asymmetric glenoid reaming produced similar, successful clinical and radiographic early to midterm outcomes for patients undergoing TSA compared with A1 glenoids. Additional follow-up on this cohort will be important to confirm the durability of these early results.

Risk Factors for Preoperative Opioid Use in Patients Undergoing Primary Anatomic Total Shoulder Arthroplasty.

The effect of preoperative opioid use in orthopedic patients has been highlighted. Numerous studies have identified worse patient outcomes with pre-operative opioid use; however, there is currently no information identifying risk factors for preoperative opioid use in the total shoulder arthroplasty (TSA) population. The purpose of this study was to determine risk factors for preoperative opioid use in patients undergoing primary anatomic TSA for primary osteoarthritis (OA) and to determine baseline preoperative patient-reported outcomes (PROs) in preoperative opioid users compared with nonopioid users. The authors studied 982 TSAs performed for primary glenohumeral joint OA in a prospective TSA registry. Patient demographic and clinical characteristics were prospectively assessed and included age; sex; socioeconomic status (SES); smoking status; body mass index (BMI); and history of chronic back pain, depression, diabetes mellitus, and heart disease. Preoperative PROs, range of motion measurements, and preoperative opioid use for shoulder pain were assessed. Overall, 254 (25.9%) of 982 total patients were taking preoperative opioids for shoulder pain in the setting of primary OA. Female sex (P=.023), younger age (P=.019), obesity (BMI >30 kg/m2) (P=.043), chronic back pain (P<.001), and lower SES (P=.002) were associated with increased preoperative opioid use following multivariate logistic regression. Patients with opioid use had significantly worse preoperative pain scores (P<.001), American Shoulder and Elbow Surgeons scores (P<.001), and total Constant scores (P<.002) compared with the non-opioid group. [Orthopedics. 2020;43(6):356-360.].