Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review.

While several proximal humerus fractures treated nonsurgically reach satisfactory outcomes, some become symptomatic malunions or nonunions with pain and dysfunction. When joint-preserving options such as malunion or nonunion repair are not optimal because of poor remaining bone stock or glenohumeral arthritis, shoulder arthroplasty is a good option. Because of the semiconstrained design of reverse shoulder arthroplasty, it is effective at improving function when there is notable bony deformity or a torn rotator cuff. Clinical studies have demonstrated reliable outcomes, and a classification system exists that is helpful for predicting prognosis and complications. By understanding the associated pearls and pitfalls and with careful management of the tuberosities, reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae.

Evaluating the Healing Potential of J-Plasma Scalpel-Created Surgical Incisions in Porcine and Rat Models.

Cold atmospheric plasma devices generate reactive oxygen and nitrogen species that can be anti-microbial but also promote cell migration, differentiation, and tissue wound healing. This report investigates the healing of surgical incisions created using cold plasma generated by the J-Plasma scalpel (Precise Open handpiece, Apyx Medical, Inc.) compared to a steel scalpel in in vivo porcine and rat models. The J-Plasma scalpel is currently FDA approved for the delivery of helium plasma to cut, coagulate, and ablate soft tissue during surgical procedures. To our knowledge, this device has not been studied in creating surgical incisions but only during deeper dissection and hemostasis. External macroscopic and histologic grading by blinded reviewers revealed no significant difference in wound healing appearance or physiology in incisions created using the plasma scalpel as compared with a steel blade scalpel. Incisions created with the plasma scalpel also had superior hemostasis and a reduction in tissue and blood carryover. Scanning electron microscopy (SEM) and histology showed collagen fibril fusion occurred as the plasma scalpel incised through the tissue, contributing to a sealing effect. In addition, when bacteria were injected into the dermis before incision, the plasma scalpel disrupted the bacterial membrane as visualized in SEM images. External macroscopic and histologic grading by blinded reviewers revealed no significant difference in wound healing appearance or physiology. Based on these results, we propose additional studies to clinically evaluate the use of cold plasma in applications requiring hemostasis or when an increased likelihood of subdermal pathogen leakage could cause surgical site infection (i.e., sites with increased hair follicles).

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Effect of vitamin E-enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene.

BACKGROUND: Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component's mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E-enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E-enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component. METHODS: Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated. RESULTS: The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05). CONCLUSIONS: A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E-enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.

Surprise Billing in Elective Shoulder Surgery and Its Effect on Patient Satisfaction.

Patients often receive multiple bills following surgery, which may come as a surprise to them if they are not appropriately informed or educated prior to surgery. The purpose of this study was to identify whether surprise billing occurs following shoulder rotator cuff repair and its effect on patient satisfaction. The study surveyed adult patients who underwent elective rotator cuff repair from January 2020 to October 2021. Patients were asked if they received unexpected bills after their surgery, as well as about details regarding those bills. Additionally, patients were asked about their medical insurance carrier, knowledge of the billing process prior to surgery, and how they felt the process could be improved. Finally, patients were asked how these bills and the overall billing process affected their surgical satisfaction. Of the 158 responses, 25% of the patients stated they received at least one surprise bill following their rotator cuff surgery, with 57% of these bills being greater than $1000. Patients who received surprise bills reported being significantly less satisfied with their surgery (P<.001) and felt their billing experience affected their surgical satisfaction (64% vs 9%, P<.001). One in 4 patients undergoing elective rotator cuff repair received a surprise bill following surgery. These bills were monetarily substantial and significantly affected surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(2):123-127.].

Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group.

BACKGROUND: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants. METHODS: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA. RESULTS: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001). CONCLUSION: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.

Elliptical Humeral Head Implants in Anatomic Total Shoulder Arthroplasty.

Humeral implants for anatomic total shoulder arthroplasty and hemiarthroplasty have typically used spherical humeral heads that have a uniform diameter and radius of curvature. However, the native humeral head has a more elliptical morphology, which has spurred interest in nonspherical implant designs. Cadaveric studies indicate that the native humeral head diameter is 10% longer in the superior-inferior plane than the anterior-posterior plane and has a radius of curvature that is approximately 8% greater. An elliptical implant that more closely replicates native anatomy may allow for more accurate coverage of the humeral resection surface with less implant overhang and risk of overstuffing. Biomechanical evidence suggests that an elliptical implant yields glenohumeral kinematics that mimic the native joint, and early clinical results are promising. As clinical research continues to emerge, it will become clearer whether encouraging cadaveric, biomechanical, and early clinical data translates to meaningful sustained improvements in patient outcomes.

Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group.

BACKGROUND: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status. METHODS: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis. RESULTS: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort. CONCLUSION: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.

Protein-Based Fat Replacers: A Focus on Fabrication Methods and Fat-Mimic Mechanisms.

The increasing occurrence of obesity and other non-communicable diseases has shifted the human diet towards reduced calorie intake. This drives the market to develop low-fat/non-fat food products with limited deterioration of textural properties. Thus, developing high-quality fat replacers which can replicate the role of fat in the food matrix is essential. Among all the established types of fat replacers, protein-based ones have shown a higher compatibility with a wide range of foods with limited contribution to the total calories, including protein isolate/concentrate, microparticles, and microgels. The approach to fabricating fat replacers varies with their types, such as thermal-mechanical treatment, anti-solvent precipitation, enzymatic hydrolysis, complexation, and emulsification. Their detailed process is summarized in the present review with a focus on the latest findings. The fat-mimic mechanisms of fat replacers have received little attention compared to the fabricating methods; attempts are also made to explain the underlying principles of fat replacers from the physicochemical prospect. Finally, a future direction on the development of desirable fat replacers in a more sustainable way was also pointed out.

Arthroscopic Transosseous Rotator Cuff Repair.

Open transosseous rotator cuff repair (RCR) was the original benchmark surgical technique for RCR. The advent of arthroscopic and suture anchor technology shifted the paradigm from open to arthroscopic surgery. Although technological advances have progressed, they come at a cost. Suture anchor technology is expensive, optimal constructs have yet to be determined, and the technology may lead to challenging complications and revision scenarios. In more recent years, a return to transosseous bone tunnels has been described with new arthroscopic techniques, eliminating the need for suture anchors. The purpose of this article is to review the historical, biomechanical, clinical, and economic literature surrounding arthroscopic transosseous RCR.

Effect of reverse shoulder arthroplasty humeral component retroversion on acromial strain.

INTRODUCTION: Acromion and scapular spine stress fractures can be catastrophic complications following reverse shoulder arthroplasty (RSA). A variety of host, implant, and technical factors have been identified that increase the risk of this complication. The glenoid component in particular has been closely evaluated for its impact on rates of stress fractures following RSA. The goal of this biomechanical study is to evaluate if humeral stem version has an impact on acromion and scapular spine strain after RSA. METHODS: Eight cadaveric specimens were tested on a custom dynamic shoulder frame. Commercially available RSA components were implanted with the humeral component inserted in 0° of retroversion. Acromion and scapular spine strain were measured at 0°, 30°, and 60° of abduction using strain rosettes secured to the acromion and scapular spine in the typical locations for Levy type II and type III stress fractures, respectively. The humeral stem was then removed and reimplanted in 30° of retroversion and the measurements were repeated. Student t test was performed to analyze the relationship between humeral stem version and acromion and scapular spine strain at various abduction angles. RESULTS: Strain at the both the acromion and scapular spine were found to have no significant difference at any abduction angle when comparing 0° and 30° version of the humeral stem. With 0° and 30° versions pooled together, there is significantly lower acromion and scapular spine strain at 60° of abduction when compared to 0° of abduction (strain at 0° abduction - strain at 60° abduction: acromion 313.1 µêœª; P = .0409, Scapular spine 304.9 µêœª; P = .0407). There was no significant difference in strain at either location when comparing 0° of abduction to 30° of abduction and when comparing 30° of abduction to 60° of abduction. CONCLUSIONS: This biomechanical study found no significant difference in scapular spine and acromion strain after RSA when comparing variations in humeral stem version. There does appear to be lower strain at both the acromion and scapular spine at 60° of abduction when compared to 0° of abduction regardless of stem version.

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

BACKGROUND: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. METHODS: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. RESULTS: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006). CONCLUSION: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

The Incidence of Symptomatic Mediastinal Compromise Following Medial Clavicle Fractures.

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [Orthopedics. 2023;46(3):e161-e166.].

Return to driving following anatomic and reverse shoulder arthroplasty: a comparative analysis.

BACKGROUND: The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA). METHODS: All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery). RESULTS: Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively. CONCLUSION: Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

Malpractice against shoulder surgeons: what the data say.

BACKGROUND: Thousands of orthopedic surgeons in the United State face medical malpractice claims annually; however, little is known regarding the common causes for litigation against shoulder surgeons. In addition, the current analysis does not take into consideration how surgical frequency affects the litigation likelihood. The purpose of our investigation was to identify the most common causes of litigation against shoulder surgeons in the United States adjusting for surgical frequency. METHODS: The VerdictSearch database was used using the search terms "medical malpractice," "shoulder," and "NOT cancer." Results were queried, and all studies pertaining to orthopedic shoulder surgery included. Data gathered included cause of lawsuit, indemnity paid, type of surgery performed, results of the cases, verdict or settlement, and, if applicable, technical error. A query of a multisurgeon institutional database was conducted to determine how frequently surgeries were performed. Then the frequency of litigation was adjusted by the procedure frequency to determine which surgery has the greatest likelihood to be litigated relative to rotator cuff surgery. RESULTS: Forty-five cases were included in our study. After adjusting for the procedure frequency, the most likely procedure to be litigated, relative to rotator cuff repair, was manipulation under anesthesia (MUA), 251 times more likely to be litigated, and washout/lavage procedures, 17 times more likely to be litigated. Injection and total shoulder arthroplasty were 23 and 14 times less likely to be litigated relative to rotator cuff repair, respectively. In addition, the average age of the patients was 47 years, and 53% of the cases involved a male plaintiff. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement. CONCLUSIONS: This study identifies that MUA and lavage/washout procedures are much more likely to be litigated relative to rotator cuff repair. Rotator cuff repair is actually one of the least likely procedures to be litigated. Furthermore, settlement may represent a method of decreasing the indemnity paid for malpractice cases for which surgeons are implicated.

Fixed- vs. variable-angle humeral neck cut in anatomic total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Variable neck-shaft angle (NSA) stemmed humeral components have been incorporated into certain implant designs to better re-create normal anatomy in total shoulder arthroplasty (TSA). The purpose of this study was to determine if premorbid glenohumeral joint anatomy is better restored with a fixed- vs. variable-NSA prosthesis. METHODS: A randomized controlled trial was performed including 50 patients with osteoarthritis indicated for primary anatomic TSA. Patients were randomized preoperatively to receive either a variable- (n = 26) or fixed-NSA (n = 24) prosthesis. Humeral neck cut in the variable-NSA group matched the patient's anatomic neck, with prosthetic NSA of 127.5°, 132.5°, and 137.5° available. Fixed-NSA cuts were made with an intramedullary guide of 132.5°. Preoperative and postoperative radiographs were evaluated for specific radiographic anatomic variables: NSA, head thickness, tuberosity-to-head height, head offset, articular arc, greater tuberosity offset, and center of rotation (COR). Postoperative radiographic criteria were compared between groups. RESULTS: No differences were found between groups in demographics or preoperative radiographic measures. When comparing average difference in preoperative and postoperative measurements in the fixed-NSA group, the humeral head offset from the humeral shaft axis significantly decreased by 1.4 mm (P = .046), and the COR moved superiorly (3.0 mm, P = .002) without significant medialization or lateralization. In the variable angle group, humeral head offset decreased but did not reach significance (1.2 mm, P = .091), and the COR also moved superiorly (2.9 mm, P < .001) without significant medialization or lateralization. All remaining radiographic parameters did not significantly change from pre- to postoperative imaging. In comparing the fixed- and variable-NSA groups' net change from the premorbid measurements, no significant differences were found in tuberosity-to-head height, head offset, or COR position in both the horizontal and vertical planes. CONCLUSIONS: Both fixed- and variable-NSA anatomic TSA humeral components demonstrate adequate restoration of premorbid anatomy radiographically.

Biomechanical comparison of elbow stability constructs.

BACKGROUND: Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. METHODS: Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. RESULTS: Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. CONCLUSION: The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

The Opioid Risk Tool: Can This Validated Tool Predict Post-Operative Opioid Dependence Following Arthroscopic Rotator Cuff Repair?

Background: Numerous attempts have been made to decrease the incidence of opioid dependence after orthopedic surgeries. However, no effective means of preoperative risk stratification currently exists. The purpose of this study was to determine the ability of the Opioid Risk Tool (ORT) to predict the rate of opioid dependence 2 years after arthroscopic rotator cuff repair (ARCR). Methods: We prospectively evaluated all patients undergoing primary ARCR at a single institution over a 1.5 year period with a minimum of 2-year follow-up. All patients completed the ORT prior to surgery and were stratified into Low, Moderate, and High risk categories. The primary outcome was postoperative opioid dependence, defined as receiving a minimum of 6 opioid prescriptions within 2 years following surgery. Secondary outcomes included the total number of morphine milligram equivalents prescribed, total number of opioid prescriptions filled, and total number of opioid pills prescribed during this time interval. All outcome variables were compared amongst Low, Moderate, and High risk groups. Assessment of a statistical correlation between each outcome variable and individual numerical ORT scores (1-9) was performed. Results: A total of 137 patients were included for analysis. No statistically significant difference was noted in any primary or secondary outcome variable when compared between Low, Moderate, and High risk groups. The total cohort demonstrated a 19% rate of post-operative opioid dependence. No correlation was identified between any outcome variable and individual numerical ORT scores. A greater rate of dependence and quantity of opioids prescribed was noted amongst patients with a history of prior opioid use. Conclusion: The ORT was not predictive of the risk of opioid dependence or quantity of opioids prescribed after ARCR. Attention should be focused on alternative means of identification and management of patients at risk for opioid dependence after orthopedic procedures, including those with a history of prior opioid use.

Midterm outcomes and survivorship of arthroscopic elbow debridement: a comparison of posttraumatic versus primary degenerative osteoarthritis.

BACKGROUND: Arthroscopic debridement is an effective means of surgical management of both degenerative osteoarthritis (DOA) and posttraumatic arthritis (PTA) of the elbow. However, the difference in the efficacy and longevity of this procedure when performed for these two distinct pathologies remains in question. The purpose of this study was to identify and compare the midterm outcomes and survivorship of arthroscopic debridement of elbow PTA and DOA. METHODS: A retrospective analysis of patients undergoing arthroscopic debridement of DOA and PTA of the elbow was performed. A questionnaire containing the Oxford Elbow Score, as well as questions regarding the incidence of reoperation, additional nonoperative intervention, complications, pain, and satisfaction, was given at 5 years, minimum, after surgery. The midterm survivorship of arthroscopic debridement free of reoperation for any reason, as well as the remaining outcome measurements obtained via the questionnaire and in-office evaluation, was compared between PTA and DOA cohorts. RESULTS: Eighty patients (DOA = 36, PTA = 44) were included in this study for analysis. All 36 patients with DOA were noted to be male. Follow-up time at the date of questionnaire response was 7.9 years (range, 5.6-11.8) in the DOA cohort and 8.6 years (range, 5.7-12.7) in the PTA cohort. Reoperation rates of 5.6% and 11.4% were identified in the DOA and PTA cohorts, respectively. No statistical difference was noted in reoperation rate, survivorship, or any measured patient-reported outcomes between cohorts at the final follow-up visit. Both cohorts demonstrated a significant improvement in Visual Analog Scale pain scores (P < .001) and ROM. Postoperative ROM was obtained at the final clinic visit at an average follow-up duration of 151 days and 255 days in the DOA and PTA cohorts, respectively. However, no difference in the degree of improvement in either outcome variable was identified after a comparison between cohorts. CONCLUSION: Arthroscopic debridement is an equally efficacious treatment option for DOA and PTA of the elbow. Patients with either pathology can expect satisfactory elbow function and an improvement in pain with little chance of reoperation at the midterm of the follow-up duration.