Episode-based cost reduction for endovascular aneurysm repair.

OBJECTIVE: Effective strategies to reduce costs associated with endovascular aneurysm repair (EVAR) remain elusive for many medical centers. In this study, targeted interventions to reduce inpatient EVAR costs were identified and implemented. METHODS: From June 2015 to February 2016, we analyzed the EVAR practice at a high-volume academic medical center to identify, to rank, and ultimately to reduce procedure-related costs. In this analysis, per-patient direct costs to the hospital were compared before (September 2013-May 2015) and after (March 2016-January 2017) interventions were implemented. Improvement efforts concentrated on three categories that accounted for a majority of costs: implants, rooming costs, and computed tomography scans performed during the index hospitalization. RESULTS: Costs were compared between 141 EVAR procedures before implementation (PRE period) and 47 EVAR procedures after implementation (POST period). Based on data obtained through the Society for Vascular Surgery EVAR Cost Demonstration Project, it was determined that implantable device costs were higher than those at peer institutions. New purchasing strategies were implemented, resulting in a 30.8% decrease in per-case device costs between the PRE and POST periods. Care pathways were modified to reduce use of and costs for computed tomography scans obtained during the index hospitalization. Compared with baseline, per-case imaging costs decreased by 92.9% (P < .001), including a 99.0% (P = .001) reduction in postprocessing costs. Care pathways were also implemented to reduce preprocedural rooming for patients traveling long distances the day before surgery, resulting in a 50% decrease in utilization rate (35.4% PRE to 17.0% POST; P = .021), without having a significant impact on median postprocedural length of stay (PRE, 2 days [interquartile range, 1-11 days]; POST, 2 days [1-7 days]; P = .185). Medication costs also decreased by 38.2% (P < .001) as a hospital-wide effort. CONCLUSIONS: Excessive costs associated with EVAR threaten the sustainability of these procedures in health care organizations. Targeted cost reduction efforts can effectively reduce expenses without compromising quality or limiting patients' access.

Acromial spine fracture after reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) accounts for nearly one-third of shoulder arthroplasty utilization nationally. The complication rate has increased concurrently. Consensus is lacking regarding the incidence, etiology, and treatment of acromial or scapular spine fractures after RSA. The purpose of our study was to perform a systematic review of the literature to analyze the occurrence and outcomes of this complication. METHODS: The MEDLINE, Embase, Google Scholar, and Cochrane databases were queried in late 2017 for combinations of the words "acromial," "fracture," "reverse," "shoulder," and "arthroplasty." We included all studies that contained a clearly defined performance of RSA, acromial fracture(s) noted, and treatment (if any) and outcomes of treatment. The initial search yielded 50 studies; 32 met the inclusion criteria. RESULTS: Among 3838 RSAs, 159 acromial fractures were reported, for an overall incidence of 4.14%; the mean time to diagnosis from surgery was 9 months (range, 1.3-24 months). Treatments included nonoperative treatment in a sling or abduction brace in 139 cases and open reduction-internal fixation in 20. Regardless of treatment, patients reported inferior function after fracture compared with initially after RSA. Forward flexion was 95° (range, 30°-110°), abduction was 76° (range, 30°-180°), the Constant score was 63 (range, 59-67.5), and the American Shoulder and Elbow Surgeons score was 57 (range, 7-83); all values were reduced compared with patients without fractures. CONCLUSION: This study suggests the occurrence of acromial fractures after RSA is a common event, with a rate of over 4%. These fractures correlate with worse postoperative outcomes regardless of treatment method; open reduction-internal fixation was not shown to be clinically superior despite a limited complication rate. Additional high-quality studies addressing acromial spine fracture after RSA are needed.

Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study.

BACKGROUND: Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension. METHODS: Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks. RESULTS: The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone. CONCLUSION: A branch of the anterior humeral circumflex is a reliable landmark for identifying the mid-suprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis.

Genomewide Association Study of Alcohol Dependence Identifies Risk Loci Altering Ethanol-Response Behaviors in Model Organisms.

BACKGROUND: Alcohol dependence (AD) shows evidence for genetic liability, but genes influencing risk remain largely unidentified. METHODS: We conducted a genomewide association study in 706 related AD cases and 1,748 unscreened population controls from Ireland. We sought replication in 15,496 samples of European descent. We used model organisms (MOs) to assess the role of orthologous genes in ethanol (EtOH)-response behaviors. We tested 1 primate-specific gene for expression differences in case/control postmortem brain tissue. RESULTS: We detected significant association in COL6A3 and suggestive association in 2 previously implicated loci, KLF12 and RYR3. None of these signals are significant in replication. A suggestive signal in the long noncoding RNA LOC339975 is significant in case:control meta-analysis, but not in a population sample. Knockdown of a COL6A3 ortholog in Caenorhabditis elegans reduced EtOH sensitivity. Col6a3 expression correlated with handling-induced convulsions in mice. Loss of function of the KLF12 ortholog in C. elegans impaired development of acute functional tolerance (AFT). Klf12 expression correlated with locomotor activation following EtOH injection in mice. Loss of function of the RYR3 ortholog reduced EtOH sensitivity in C. elegans and rapid tolerance in Drosophila. The ryanodine receptor antagonist dantrolene reduced motivation to self-administer EtOH in rats. Expression of LOC339975 does not differ between cases and controls but is reduced in carriers of the associated rs11726136 allele in nucleus accumbens (NAc). CONCLUSIONS: We detect association between AD and COL6A3, KLF12, RYR3, and LOC339975. Despite nonreplication of COL6A3, KLF12, and RYR3 signals, orthologs of these genes influence behavioral response to EtOH in MOs, suggesting potential involvement in human EtOH response and AD liability. The associated LOC339975 allele may influence gene expression in human NAc. Although the functions of long noncoding RNAs are poorly understood, there is mounting evidence implicating these genes in multiple brain functions and disorders.

Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis.

BACKGROUND: As the prevalence of total hip arthroplasty (THA) expands, so too will complications and patient dissatisfaction. The goal of this study was to identify the common etiologies of malpractice suits and costs of claims after primary and revision THAs. METHODS: Analysis of 115 malpractice claims filed for alleged neglectful primary and revision THA surgeries by orthopedic surgeons insured by a large New York state malpractice carrier between 1983 and 2011. RESULTS: The incidence of malpractice claims filed for negligent THA procedures is only 0.15% per year in our population. In primary cases, nerve injury ("foot drop") was the most frequent allegation with 27 claims. Negligent surgery causing dislocation was alleged in 18 and leg length discrepancy in 14. Medical complications were also reported, including 3 thromboembolic events and 6 deaths. In revision cases, dislocation and infection were the most common source of suits. The average indemnity payment was $386,153 and the largest single settlement was $4.1 million for an arterial injury resulting in amputation after a primary hip replacement. The average litigation cost to the insurer was $61,833. CONCLUSION: Nerve injury, dislocation, and leg length discrepancy are the most common reason for malpractice after primary THA. Orthopedic surgeons should continue to focus on minimizing the occurrence of these complications while adequately incorporating details about the risks and limitations of surgery into their preoperative education.

Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy.

PURPOSE: To determine factors associated with grade IV cartilage defects in the hip in patients undergoing hip arthroscopy with joint pain. METHODS: Data from consecutive patients who underwent hip arthroscopy performed by a single surgeon over a period of 4 years were included in this study. The study group included 1,097 patients (491 women and 606 men; mean age, 37 years) who underwent hip arthroscopy for pain, had no prior hip surgery, and were aged 18 years or older. Preoperative radiographs, patient demographic characteristics, and operative details were used to identify risk factors for cartilage defects. RESULTS: Grade IV chondral defects were present in 308 of 1,097 hips (28%). Isolated chondral lesions were more frequently observed on the acetabulum (76%) than on the femoral head (24%). Defects of the acetabulum were more commonly anterosuperior (94.7%) and less commonly posterolateral (5.3%). Patients with less than 2 mm of joint space on preoperative radiographs were 8 times more likely to have a grade IV lesion than those with more than 2 mm. Men were more likely than women to have grade IV lesions (35% v 19%, P = .0001); patients with grade IV lesions were older than those without (42 years v 34 years, P = .0001). Hips with grade IV lesions had significantly higher alpha angles than those without (74° v 70°, P = .0001). Patients with grade IV defects reported a longer duration of symptoms than those without (37 months v 27 months, P = .007). Independent risk factors for the presence of grade IV chondral defects were less than 2 mm of joint space, male gender, increasing age, larger alpha angle, and longer duration of symptoms. CONCLUSIONS: Grade IV chondral defects in patients undergoing hip arthroscopy were associated with decreased joint space, increased time from symptom onset to arthroscopy, male gender, and larger alpha angles associated with femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Outcomes of patients with low-risk endometrial cancer surgically staged without lymphadenectomy based on intra-operative evaluation.

OBJECTIVE: The objective of the study was to evaluate clinical outcomes in patients with stage I endometrial cancer undergoing surgical management without lymphadenectomy based on intra-operative assessment for low-risk disease. METHODS: Between 2000 and 2009, a total of 179 patients were surgically staged without lymphadenectomy for low-risk stage I endometrial cancer. Low-risk cancer was defined by intra-operative criteria based on both gross and frozen tissue microscopic evaluation: 1) G1 or G2 endometrioid histology; 2) myoinvasion <50%; 3) no cervical disease, and 4) no intra-abdominal metastasis. Records were reviewed for postoperative complications, pathological diagnoses, adjuvant radiation treatment, cancer recurrence, and mortality. RESULTS: Morbidity, cancer recurrence, and disease-specific mortality were low. Postoperative complications occurred in 5 patients (2.8%). Nine patients (5.0%) were offered adjuvant radiation for higher risk disease diagnosed on final pathology. Radiation morbidity was minimal: grade 1 vaginal toxicity in 2 patients. Three patients (1.7%) experienced recurrent cancer with mean time to recurrence of 43.7 months. Five year overall survival was 95.8%. The five year probability of disease-specific death was 1.1%. CONCLUSION: In an institution with reliable capability of pathological frozen tissue diagnosis, omission of lymph node dissection is a reasonable option in the surgical management of those patients with low-risk disease diagnosed by intra-operative factors.

Joint space predicts THA after hip arthroscopy in patients 50 years and older.

BACKGROUND: All patients considering joint-preserving hip arthroscopy should be educated on the risk of THA after arthroscopy. The degree of radiographic osteoarthritis predicts subsequent THA. To provide patients with the best information, the best radiographic measure that predicts THA after hip arthroscopy should be identified. QUESTIONS/PURPOSES: We therefore determined if Tönnis grade, Kellgren-Lawrence grade, or joint space narrowing was superior in predicting THA after hip arthroscopy. METHODS: We retrospectively reviewed 203 patients 50 years of age or older treated with hip arthroscopy between March 2007 and October 2010. Of these, 96 patients met the study inclusion criteria. Sixty-five did not undergo THAs during the followup time (non-THA group) and 31 patients did (THA group). We determined Tönnis grade, Kellgren-Lawrence grade, and/or joint space narrowing before arthroscopy. The median followup for the non-THA group was 54 months (95% confidence interval, 49.9-58.9 months). RESULTS: In 81% of the patients, joint space accurately predicted THA or non-THA, whereas Kellgren-Lawrence was accurate in 73% and Tönnis grade was accurate in 65%. On binary logistic regression, the only predictor (r(2) = 0.45) of THA was joint space of 2 mm or less. CONCLUSIONS: Measuring joint space by determining if any measurement is 2 mm or less predicts patients progressing to THA after hip arthroscopy approximately 80% of the time. At this early time point, joint space measurements were the most accurate predictor of THA and should be used in patient education to define the risk of early failure from hip arthroscopy.

Hip arthroscopy and femoroacetabular impingement in the pediatric patient.

Femoroacetabular impingement (FAI) is widely understood to be an underlying etiology of injuries to the acetabular labrum and cartilage in the adult hip, although somewhat less attention has previously been spent on its incidence in the pediatric and adolescent populations. Initially recognized as a consequence of periacetabular osteotomies performed for developmental dysplasia of the hip, it can also be because of a number of other disorders or to a developmental process causing irregular bony growth. The adolescent presenting with FAI is athletic, particularly in endeavors placing excessive stress on the hip and surrounding soft tissues. The pain is characterized as sharp, localized around the anatomic femoral head location, and may be associated with catching or popping. Complete physical examination includes full range of motion testing, as a hallmark of FAI is restriction and pain with internal rotation. Special tests include the anterior impingement test, the FABER test, and the dial test. Imaging includes anteroposterior pelvic and cross-table lateral radiographs and magnetic resonance imaging. Treatment in all patients is 6 weeks of conservative therapy. If patients see no improvement with conservative treatment, they may be candidates for hip arthroscopy. Arthroscopic treatment of FAI includes rim trimming for pincer lesions, osteoplasty for cam decompression and labral detachment, and repair or reconstruction for labral tears. Studies have shown improvements in the modified Harris Hip Score and the Hip Outcomes Score postoperatively. As FAI is diagnosed most frequently in athletes, and it is estimated that 30 to 45 million adolescents 6 and 18 years old are involved in sports, it is becoming imperative to identify factors that may predict its development, study treatments, and improve outcomes.

A systematic gene-based screen of chr4q22-q32 identifies association of a novel susceptibility gene, DKK2, with the quantitative trait of alcohol dependence symptom counts.

Studies of alcohol dependence (AD) have consistently found evidence of linkage on chromosome 4q21-q32. A genome-wide linkage scan in the Irish Affected Sib Pair Study of Alcohol Dependence (IASPSAD) sample also provided its strongest evidence of linkage on chromosome 4q22-q32 using an index of AD severity based on the count of DSM-IV AD symptoms (ADSX; LOD = 4.59). We conducted a systematic, gene-centric association study using 518 LD-tagging single nucleotide polymorphisms (SNPs) in the 65 known and predicted genes within the 1-LOD interval surrounding the linkage peak. Case-only regression analysis with the quantitative variable of ADSX was performed in the 562 genetically independent cases; nominal support for association was demonstrated by 32 tagging SNPs in 14 genes. We did not observe study-wide significance, but gene-wise correction for multiple testing with the Nyholt procedure yielded empirical evidence of association with two genes, DKK2 (dickkopf homolog 2) (P = 0.007) and EGF (epidermal growth factor) (P = 0.025) in the IASPSAD sample. Three SNPs in DKK2 (rs427983; rs419558; rs399087) demonstrated empirical significance. Assessment of possible replication in 847 cases of European descent from a large independent sample, the Collaborative Study of the Genetics of Alcoholism, yielded replication for DKK2 but not EGF. We observed genotypic and phenotypic replication for DKK2 with the three SNPs yielding significant association with ADSX in the IASPSAD sample. Haplotype-specific expression measurements in post-mortem tissue samples suggested a functional role for DKK2. This evidence notwithstanding, replication is needed before confidence can be placed in these findings.

Neurotransmitter and neuromodulator genes associated with a history of depressive symptoms in individuals with alcohol dependence.

BACKGROUND: Depressive symptoms are common among individuals with alcohol use disorders and impact treatment outcome. Substantial overlap exists among the neurobiological systems proposed in the pathophysiology of depressive and alcohol use disorders; however, specific genetic effects contributing to risk for depressive comorbidity remain poorly understood. METHODS: This study examines the association of depressive symptom scores for lifetime depression (the sum of DSM-IV major depression co-endorsed criteria for lifetime depression) with markers in 120 candidate genes in 554 alcohol-dependent individuals. The candidate genes code for molecules involved in dopamine, serotonin, glutamate, gamma-aminobutyric acid (GABA), and opioid neurotransmission, cell signaling, pharmacokinetics, stress biology, and behavioral control. Analyses were conducted at the single marker level with experimentwise permutation to control for multiple testing. RESULTS: Results revealed nominal associations for markers in 20 genes. Following experimentwise permutation, markers in the corticotropin-releasing hormone-binding protein (CRHBP) the µ-opioid receptor (OPRM1) and the ß1 subunit of GABA A (GABA(A)) receptors (GABRB1) met or exceeded the significance threshold. None of the markers associated with depressive symptom scores were significantly associated with alcohol dependence symptom scores. CONCLUSION: These findings suggest potential risk genes for depressive symptoms in alcohol-dependent individuals.

Limited associations of dopamine system genes with alcohol dependence and related traits in the Irish Affected Sib Pair Study of Alcohol Dependence (IASPSAD).

BACKGROUND: Over 50 years of evidence from research has established that the central dopaminergic reward pathway is likely involved in alcohol dependence (AD). Additional evidence supports a role for dopamine (DA) in other disinhibitory psychopathology, which is often comorbid with AD. Family and twin studies demonstrate that a common genetic component accounts for most of the genetic variance in these traits. Thus, DA-related genes represent putative candidates for the genetic risk that underlies not only AD but also behavioral disinhibition. Many linkage and association studies have examined these relationships with inconsistent results, possibly because of low power, poor marker coverage, and/or an inappropriate correction for multiple testing. METHODS: We conducted an association study on the products encoded by 10 DA-related genes (DRD1-D5, SLC18A2, SLC6A3, DDC, TH, COMT) using a large, ethnically homogeneous sample with severe AD (n = 545) and screened controls (n = 509). We collected genotypes from linkage disequilibrium (LD)-tagging single nucleotide polymorphisms (SNPs) and employed a gene-based method of correction. We tested for association with AD diagnosis in cases and controls and with a variety of alcohol-related traits (including age-at-onset, initial sensitivity, tolerance, maximum daily drinks, and a withdrawal factor score), disinhibitory symptoms, and a disinhibitory factor score in cases only. A total of 135 SNPs were genotyped using the Illumina GoldenGate and Taqman Assays-on-Demand protocols. RESULTS: Of the 101 SNPs entered into standard analysis, 6 independent SNPs from 5 DA genes were associated with AD or a quantitative alcohol-related trait. Two SNPs across 2 genes were associated with a disinhibitory symptom count, while 1 SNP in DRD5 was positive for association with the general disinhibitory factor score. CONCLUSIONS: Our study provides evidence of modest associations between a small number of DA-related genes and AD as well as a range of alcohol-related traits and measures of behavioral disinhibition. While we did conduct gene-based correction for multiple testing, we did not correct for multiple traits because the traits are correlated. However, false-positive findings remain possible, so our results must be interpreted with caution.

Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review.

OBJECTIVES: To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF). DATA SOURCES: PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020. STUDY SELECTION: Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded. DATA EXTRACTION: Two authors independently extracted data and appraised study quality using MINORS score. DATA SYNTHESIS: Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations. CONCLUSIONS: Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123-144°; external rotation: 42-46°; Constant score: 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for heterotopic ossification in operatively treated proximal humeral fractures.

AIMS: Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients. METHODS: A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs. RESULTS: The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment. CONCLUSION: This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539-544.

Soft tissue resurfacing for glenohumeral arthritis: a systematic review.

BACKGROUND: Severe glenohumeral arthritis in the young/active patient remains challenging. Historically, glenohumeral arthrodesis was recommended with limited return of function. Total shoulder arthroplasty has shown increasing survivorship at 15 years; however it is still not ideal for young patients. Biologic resurfacing of the glenoid with humeral head replacement has shown promising results. METHODS: The PubMed and Embase databases were queried for studies evaluating outcomes of glenoid biologic resurfacing with autograft or allograft. Two independent reviewers performed a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Eleven studies (268 shoulders, 264 patients) were included. Minimum follow-up was 24 months in all but one study; patient age ranged from 14 to 75 years. Glenoid grafts used included 44.3% lateral meniscus allografts, 25.4% human acellular dermal matrix, 14.2% Achilles tendon allografts, 11.6% shoulder joint capsules, and 4.5% fascia lata autografts. Studies reported significantly improved American Shoulder and Elbow Surgeons, Visual Analog Scale, and Simple Shoulder Test scores postoperatively; 43.3% were failures (Neer's evaluation of unsatisfactory or requiring revision). Infection occurred in 12/235. CONCLUSIONS: Biologic resurfacing of the glenoid with a metallic humeral component can provide a significant improvement in pain, motion, and standardized outcomes scores in the well-indicated situation. Appropriate counseling is required with an appreciated complication rate of over 36% and a revision rate of 34%.

No safe zone: The anatomy of the saphenous nerve and its posteromedial branches.

BACKGROUND: Following a case of medial meniscal repair via an inside-out repair, a patient developed acute postoperative electric shock-like paresthesias of the proximal medial calf with any knee flexion beyond 80°. Open saphenous nerve exploration revealed entrapment by suture material of an unnamed branch off the sartorial branch of the saphenous nerve. Symptoms resolved immediately with release. The objective of the study was to perform a cadaveric study to examine the existence and frequency of these previously under-reported branches of the sartorial branch of the saphenous nerve. METHODS: In 16 knees from eight fresh, matched whole cadavers, the medial structures of the knee were exposed, reproducible anatomical structures were identified, and previously under-described posteromedial branches of the sartorial nerve were identified and measured in relation to surrounding structures and the joint line. RESULTS: The saphenous nerve, its sartorial and infrapatellar branches, and its posteromedial branches were identified in all specimens. The sartorial nerve divided from the saphenous nerve an average of 4.8 cm proximal to the medial femoral epicondyle. Between one and four further posteromedial branches off the sartorial nerve were identified. These branches formed at a range of 5.3 cm proximal to 3.0 cm distal to the joint line. CONCLUSIONS: This cadaveric study establishes the consistent presence of a posteromedial branch off the sartorial nerve. It was consistently located near the posteromedial joint line. These branches are at risk for injury during medial meniscus repairs due to entrapment by suture materials, or during other surgical procedures near the posteromedial aspect of the knee.

Ambiguous Nomenclature in Musculoskeletal Magnetic Resonance Imaging.

INTRODUCTION: Medical vocabulary that conveys different meanings to different groups of readers can lead to confusion and potential misinterpretation of diagnoses. This article reviews words used by radiologists that convey information to the orthopedic surgeon and patient that is different from what the radiologist intended. These terms include meniscal tears, ligament sprains, partial tendon tears, bone bruises, bone contusions, articular cartilage injury, disc bulges, disc herniations, and joint subluxation. These words can, for example, suggest a traumatic etiology when in fact the condition is atraumatic, and they can imply a surgical treatment where none is indicated. This problem is further magnified in the arena of personal injury litigation. MATERIALS AND METHODS: The terms tear, bruise, contusion, injury, sprain, bulge, herniation, and subluxation are defined and analyzed for their ambiguous use, i.e., their actual versus intended meaning or other interpretation. RESULTS: Abnormalities and variations observed on musculoskeletal magnetic resonance (MR) images are often multi-factorial and may not be the source of any given patient's symptoms. The same MR image findings can have a congenital, traumatic, or degenerative source. CONCLUSIONS: Radiology vocabulary that invokes a singular traumatic event as a cause of an MRI finding can significantly mislead patients (as well as judges and juries). We propose that some terms be either avoided entirely when the findings are of uncertain etiology. At the very least, the various meanings of the terms need to be spelled out. Greater cooperation between orthopedic surgeons and radiologists on this matter would be beneficial to patient care.

Utilization and Real-world Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-based Study.

INTRODUCTION: Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty. METHODS: Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, -8.0% to -4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization. CONCLUSION: In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization. LEVEL OF EVIDENCE: Level III.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study.

BACKGROUND: Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. METHODS: Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. RESULTS: IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). CONCLUSION: In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. THE TRANSLATIONAL POTENTIAL FOR THIS ARTICLE: Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Association of ADH and ALDH genes with alcohol dependence in the Irish Affected Sib Pair Study of alcohol dependence (IASPSAD) sample.

BACKGROUND: The genes coding for ethanol metabolism enzymes [alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH)] have been widely studied for their influence on the risk to develop alcohol dependence (AD). However, the relation between polymorphisms of these metabolism genes and AD in Caucasian subjects has not been clearly established. The present study examined evidence for the association of alcohol metabolism genes with AD in the Irish Affected Sib Pair Study of alcohol dependence. METHODS: We conducted a case-control association study with 575 independent subjects who met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, AD diagnosis and 530 controls. A total of 77 single nucleotide polymorphisms (SNPs) in the seven ADH (ADH1-7) and two ALDH genes (ALDH1A1 and ALDH2) were genotyped using the Illumina GoldenGate protocols. Several statistical procedures were implemented to control for false discoveries. RESULTS: All markers with minor allele frequency greater than 0.01 were in Hardy-Weinberg equilibrium. Numerous SNPs in ADH genes showed association with AD, including one marker in the coding region of ADH1C (rs1693482 in exon6, Ile271Gln). Haplotypic association was observed in the ADH5 and ADH1C genes, and in a long haplotype block formed by the ADH1A and ADH1B loci. We detected two significant interactions between pairs of markers in intron 6 of ADH6 and intron 12 of ALDH2 (p = 5 x 10(-5)), and 5' of both ADH4 and ADH1A (p = 2 x 10(-4)). CONCLUSION: We found evidence for the association of several ADH genes with AD in a sample of Western European origin. The significant interaction effects between markers in ADH and ALDH genes suggest possible epistatic roles between alcohol metabolic enzymes in the risk for AD.