Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality. Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys. Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8). Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management. Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

Effects of Scapular Angular Deviations on Potential for Rotator Cuff Tendon Mechanical Compression.

Background: One proposed mechanism of rotator cuff disease is scapular motion impairments contributing to rotator cuff compression and subsequent degeneration. Purpose: To model the effects of scapular angular deviations on rotator cuff tendon proximity for subacromial and internal mechanical impingement risk during scapular plane abduction. Study Design: Descriptive laboratory study. Methods: Three-dimensional bone models were reconstructed from computed tomography scans obtained from 10 asymptomatic subjects and 9 symptomatic subjects with a clinical presentation of impingement syndrome. Models were rotated to average scapular orientations from a healthy dataset at higher (120°) and lower (subject-specific) humeral elevation angles to investigate internal and subacromial impingement risks, respectively. Incremental deviations in scapular upward/downward rotation, internal/external rotation, and anterior/posterior tilt were imposed on the models to simulate scapular movement impairments. The minimum distance between the rotator cuff insertions and potential impinging structures (eg, glenoid, acromion) was calculated. Two-way mixed-model analyses of variance assessed for effects of scapular deviation and group. Results: At 120° of humerothoracic elevation, minimum distances from the supraspinatus and infraspinatus insertions to the glenoid increased with ≥5° changes in upward rotation (1.6-9.8 mm, P < .001) or external rotation (0.9-5.0 mm, P≤ .048), or with ≥10° changes in anterior tilt (1.1-3.2 mm, P < .001). At lower angles, ≥20° changes in most scapular orientations significantly increased the distance between the supraspinatus and infraspinatus insertions and the acromion or coracoacromial ligament. Conclusion: A reduction in scapular upward rotation decreases the distance between the rotator cuff tendon insertions and glenoid at 120° humerothoracic elevation. Interpretation is complicated for lower angles because the humeral elevation angle was defined by the minimum distance. Clinical Relevance: These results may assist clinical decision making regarding the effects of scapular movement deviations in patients with rotator cuff pathology and scapular dyskinesia and may help inform the selection of clinical interventions.

Quantification of the passive behavior of the glenohumeral joint: A biomechanical study.

Shoulder stabilization and arthroplasty procedures aim to restore the complex motion innate to the glenohumeral joint relying on proper tensioning of the surrounding soft-tissues at the time of surgery. Joint instability remains a leading cause for revisions of these procedures necessitating a deeper understanding of the passive constraint of the intact glenohumeral joint. The current literature lacks comprehensive analysis of the passive glenohumeral joint in all degrees-of-freedom (DOF). The objective of the present study is to better understand this complex joint by quantifying the passive laxity of the glenohumeral joint in multiple DOFs over a range of motion. Sixteen fresh-frozen cadaveric shoulders were tested in the intact state using a robotic simulator capable of six-DOF motion. The limits of range of motion was quantified in separate laxity tests applying a ± 2 Nm internal-external (IE) torque, ±20 N anterior-posterior (AP) force, ±20 N superior-inferior (SI) force and a 44 N distraction force at six levels of glenohumeral abduction. Overall, glenohumeral joint laxity was greatest between 15° and 45° of abduction except for SI translation which increased with abduction. IE rotation and AP translation were dominated by external rotation and anterior translation, respectively. Although early abduction and late abduction produced similar laxities, the increase in laxity in the mid abduction range indicates it is important to assess the shoulder joint throughout the range of motion and not just at these two end points. The presented laxity data establishes a baseline for intact shoulder laxity over a range of motion in multiple DOFs under known loading conditions.

The long head of the biceps tendon undergoes multiaxial deformation during shoulder motion.

The long head biceps tendon (LHBT) is presumed a common source of shoulder joint pain and injury. Despite common LHBT pathologies, diagnosis and preferred treatment remain frequently debated. This Short Communication reports the development of a subject-specific finite element model of the shoulder joint based on one subject's 3D reconstructed anatomy and 3D in vivo kinematics recorded from bone-fixed electromagnetic sensors. The primary purpose of this study was to use the developed finite element model to investigate the LHBT mechanical environment during a typical shoulder motion of arm raising. Furthermore, this study aimed to assess the viability of material models derived from uniaxial tensile tests for accurate simulation of in vivo motion. The findings of our simulations indicate that the LHBT undergoes complex multidimensional deformations. As such, uniaxial material properties reported in the existing body of literature are not sufficient to simulate accurately the in vivo mechanical behavior of the LHBT. Further experimental tests on cadaveric specimens, such as biaxial tension and combinations of tension and torsion, are needed to describe fully the mechanical behavior of the LHBT and investigate its mechanisms of injury.

American Shoulder and Elbow Surgeons score: what does it tell us about patients selecting operative treatment of a rotator cuff injury?

Background: As shared decision-making rises in importance and minimum clinically important differences become benchmarks for treatment success or failure based on the increased usage of patient-reported outcomes, it is important to understand the breadth of starting points for patients as that should affect the interpretation of individual postoperative score changes. Methods: This is a retrospective data review of prospectively collected American Shoulder and Elbow Surgeons (ASES) score of patients electing to undergo rotator cuff repair with 1-year follow-up. A residual improvement: possible to achieve ratio (RIPAR) was calculated to demonstrate what percent of maximal possible improvement was gained at 1 year. A minimal clinically important difference (MCID) of 12 was used. Results: Three hundred thirty-five patients with an age range of 32-79 years form the population. Baseline ASES score ranged from 0 to 97.5, with a mean of 47.8. At 1 year, the mean was 84.7 (range, 30-100). There was no statistical difference by age, but men reported more overall preoperative dysfunction than women (50.3 vs. 44.1, P < .001). The RIPAR was on average 67%. Seventy-eight percent of the population demonstrated RIPAR scores >50% which showed improvement of over half of their preoperative deficit. Eighty-nine percent of patients achieved a positive MCID and 3% achieved a negative MCID. Conclusions: The ASES scores showed a broad range of baseline scores for patients choosing to undergo rotator cuff repair highlighting the need for individual patient rather than population review of patient-reported outcome measures. As shared decision-making is taking on a larger role in clinical care, it is important to counsel patients accurately. Evaluating the ASES score by MCID and maximal possible improvement provides different population perspectives with the concept of RIPAR allowing for personalization of decision-making on the individual patient level.

To what extent do typical components of shoulder clinical evaluation explain upper-extremity disability? A cross-sectional study.

BACKGROUND: Physical therapists use several evaluation measures to identify the most important factors related to disability. However, the degree to which these evaluation components explain shoulder disability is not well known and that may detract clinicians from the best clinical reasoning. OBJECTIVE: To determine how much evaluation components explain shoulder function. METHODS: Eighty-one individuals with unilateral shoulder pain for at least four weeks and meeting clinical exam criteria to exclude cervical referred pain, adhesive capsulitis, and shoulder instability, participated in this study. Several typical clinical evaluation components were assessed as potential independent variables in a regression model using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a proxy to shoulder function. Two multivariate models were built to include (1) evaluation components from physical exam plus clinical history and (2) a model considering all previous variables and magnetic resonance imaging (MRI) data. RESULTS: Pain catastrophizing was the best variable in the model explaining at least 10% of the DASH variance. Sex and lower trapezius muscle strength explained considerably less of shoulder function. The MRI data did not improve the model performance. CONCLUSION: The complexity of shoulder function is not independently explained by pathoanatomical abnormalities. Psychological aspects may explain more of shoulder function even when combined with physical components in some patients.

Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification.

Diagnostic classification is a foundational underpinning of providing care of the highest quality and value. Diagnosis is pattern recognition that can result in categories of conditions that ideally direct treatment. While pathoanatomic diagnoses are common and traditional in orthopaedic practice, they often are limited with regard to directing best practice physical therapy intervention. Replacement of pathoanatomic labels with non-specific regional pain labels has been proposed, and occurs frequently in clinical practice. For example non-specific low back pain or shoulder pain of unknown origin. These labels avoid some disadvantages of tissue specific pathoanatomic labels, but are not specific enough to direct treatment. A previously introduced movement system diagnostic framework is proposed and updated with application to shoulder conditions. This framework has potential for broad development and application across musculoskeletal physical therapist practice. Movement system diagnostic classification can advance and streamline practice if considered while recognizing the inherent movement variability across individuals.

Evaluation of Diaphragmatic Function after Interscalene Block with Liposomal Bupivacaine: A Randomized Controlled Trial.

BACKGROUND: Interscalene blocks provide analgesia for shoulder surgery but also cause phrenic nerve paralysis. Liposomal bupivacaine is approved for use in interscalene blocks with the potential to provide longer pain control. However, the impact of liposomal bupivacaine on the phrenic nerve has not been evaluated. It was hypothesized that patients who received an interscalene block with both bupivacaine and liposomal bupivacaine would have a decreased diaphragmatic excursion when compared to bupivacaine alone at 24 h. METHODS: This was a double-blinded study of adult patients who were randomized to receive an interscalene block with either 20 ml 0.5% bupivacaine (bupivacaine group) or 10 ml 0.5% bupivacaine plus 10 ml liposomal bupivacaine (liposomal bupivacaine group). Twenty-six patients were randomized with 22 included in the analysis. Diaphragmatic excursion (via ultrasound) and spirometry were assessed before the block, in the postanesthesia care unit, and at 24 h postblock. The primary outcome was diaphragm excursion with sigh. No adverse events were observed. RESULTS: At 24 h, the liposomal bupivacaine group median [25th, 75th], had a greater percent change in diaphragmatic excursion during sigh breath compared to the bupivacaine group, -24% [-30, -9] versus 9% [-8, 26], difference in location, 32 (95% CI, 12 to 52), P = 0.007. Five patients in the liposomal bupivacaine group had a greater than 25% reduction in diaphragmatic excursion at 24 h versus zero in the bupivacaine group. They also had a significantly greater percent reduction in forced expiratory volume in 1 s and forced vital capacity compared with the bupivacaine group at 24 h (median decrease of 22% vs. 2%, P = 0.006, and median decrease of 19% vs. 1%, P = 0.049, respectively). CONCLUSIONS: The addition of liposomal bupivacaine to bupivacaine in an interscalene block results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement when compared to bupivacaine alone. This reduction, however, falls within the range of normal diaphragmatic function.

Endosteal plating in proximal humerus fractures: a novel technique and alternative to fibular strut allograft for medial column support.

Hypothesis: The purpose of this retrospective study is to investigate the clinical and radiographic outcomes associated with the use of a standard metal plate as an endosteal implant in combination with a lateral locking plate to treat 4 patients with displaced proximal humerus fractures. Methods: A retrospective case series study design was utilized, and the medical records of 4 patients with displaced, 3-part proximal humerus fractures treated using this technique between January 2019 and July 2021 were reviewed for this study. The mean age was 52 years (range, 44-57 years). The radiographic outcome of interest was humeral neck-shaft angle preoperatively, intraoperatively, and at the latest follow-up. The average follow-up duration was 62 weeks (range, 12-161 weeks). Results: All fractures healed without loss of reduction or neurovascular deficits. Avascular necrosis was not observed in the 2 patients with sufficient follow-up time to make such an evaluation. The average neck-shaft angles preoperatively, intraoperatively, and at the latest follow-up were 104.8°, 139.8°, and 137°, respectively. Conclusion: Locking plate technology augmented with an endosteal plate provided stable reduction and restoration of physiologic alignment in a small number of patients with displaced proximal humerus fractures. This construct creates a second column of fixation, providing medial column support, and could be removed in the event of a future revision to a reverse shoulder arthroplasty.

Kinematics and biomechanical validity of shoulder joint laxity tests as diagnostic criteria in multidirectional instability.

BACKGROUND: Clinical laxity tests are commonly used together to identify individuals with multidirectional instability (MDI). However, their biomechanical validity in distinguishing distinct biomechanical characteristics consistent with MDI has not been demonstrated. OBJECTIVE: To determine if differences in glenohumeral (GH) joint laxity exist between individuals diagnosed with multidirectional instability (MDI) and asymptomatic matched controls without MDI. METHODS: Eighteen participants (9 swimmers with MDI, 9 non-swimming asymptomatic matched controls without MDI) participated in this observational study. Participants were classified as having MDI with a composite laxity score from three laxity tests (anterior/posterior drawer and sulcus tests). Single plane dynamic fluoroscopy captured joint motion with 2D-3D joint registration to derive 3D joint kinematics. Average GH translations occurring during the laxity tests were compared between groups using an independent sample's t-test. The relationship of composite laxity scores to overall translations was examined with a simple linear regression. Differences of each laxity test translation between groups were analyzed with a two-way repeated measures ANOVA. RESULTS: Mean composite translations for swimmers were 1.7 mm greater (p = 0.04, 95% Confidence Interval (CI): 0.1, 3.3 mm) compared to controls. A moderate association occurred (r2 = 0.40, p = 0.005) between composite laxity scores and composite translation. Greater translations for the posterior drawer (-2.4 mm, p = 0.04, 95% CI: -0.1, -4.6) and sulcus tests (-2.7 mm, p = 0.03, 95% CI: -0.3, -5.0) existed in swimmers compared to controls. CONCLUSION: Significant differences in composite translation existed between symptomatic swimmers with MDI and asymptomatic control participants without MDI during GH joint laxity tests. The results provide initial biomechanically based construct validity for the clinical criteria used to identify individuals with MDI.

Supraspinatus-to-Glenoid Contact Occurs During Standardized Overhead Reaching Motion.

BACKGROUND: Rotator cuff tears may result from repeated mechanical deformation of the cuff tendons, and internal impingement of the supraspinatus tendon against the glenoid is one such proposed mechanism of deformation. PURPOSE: To (1) describe the changing proximity of the supraspinatus tendon to the glenoid during a simulated overhead reaching task and (2) determine the relationship between scapular morphology and this proximity. Additionally, the patterns of supraspinatus-to-glenoid proximity were compared with previously described patterns of supraspinatus-to-coracoacromial arch proximity. STUDY DESIGN: Descriptive laboratory study. METHODS: Shoulder models were created from magnetic resonance images of 20 participants. Standardized kinematics were imposed on the models to simulate functional reaching, and the minimum distances between the supraspinatus tendon and the glenoid and the supraspinatus footprint and the glenoid were calculated every 5° between 0° and 150° of humerothoracic elevation. The angle at which contact between the supraspinatus and the glenoid occurred was documented. Additionally, the relationship between glenoid morphology (version and inclination) and the contact angle was evaluated. Descriptive statistics were calculated for the minimum distances, and glenoid morphology was assessed using Pearson correlation coefficients and simple linear regressions. RESULTS: The minimum distances between the tendon and the glenoid and between the footprint and the glenoid decreased as elevation increased. Contact between the tendon and the glenoid occurred in all participant models at a mean elevation of 123° ± 10°. Contact between the footprint and the glenoid occurred in 13 of 20 models at a mean of 139° ± 10°. Less glenoid retroversion was associated with lower tendon-to-glenoid contact angles (r = -0.76; R 2 = 0.58; P < .01). CONCLUSION: This study found that the supraspinatus tendon progressively approximated the glenoid during simulated overhead reaching. Additionally, all participant models eventually made contact with the glenoid by 150° of humerothoracic elevation, although anatomic factors influenced the precise angle at which contact occurred. CLINICAL RELEVANCE: Contact between the supraspinatus and the glenoid may occur frequently within the range of elevation required for overhead activities. Therefore, internal impingement may be a prevalent mechanism for rotator cuff deformation that could contribute to cuff pathology.

Perioperative Management in Reverse Total Shoulder Arthroplasty.

PURPOSE OF REVIEW: A successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient. RECENT FINDINGS: One of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile. Management of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.

Strategies for Recruiting and Retaining Women and Minorities in Orthopaedics: AOA Critical Issues Symposium.

ABSTRACT: Despite considerable attention being paid to the lack of diversity in orthopaedic surgery over the last decade, there has been very little actual change in the racial and gender demographics. This article discusses mechanisms for improving the diversity of interested programs, including reviewing potential barriers to racial and gender-based diversity programs.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making.

BACKGROUND: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability. METHODS: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. RESULTS: Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure. CONCLUSION: The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

12 Tips for Engaging Medical Students in Health Communications.

This article was migrated. The article was marked as recommended. The proliferation of misinformation during the COVID-19 pandemic provides a clear example of the harms that can occur when medical professionals do not engage with the public regarding health topics. To address this need for accessible, accurate medical information, we taught medical students a COVID-19-specific curriculum tailored to sharing this information with the lay public via social media. Through active learning, students developed their understanding of disease-specific pathophysiology, prevention techniques, treatments, and public health interventions while practicing new skills in public communication as health professionals. After two cohorts completed the course, students' high-quality medical information about COVID-19 reached >100,000 viewers. To further broaden the impact, we shared the course curriculum through the Association of American Medical College (AAMC) iCollaborative. This curriculum provides a model for future engagement of medical students in health communication with lay audiences.

Hemiarthroplasty and Total Shoulder Arthroplasty Conversion to Reverse Total Shoulder Arthroplasty.

PURPOSE OF REVIEW: The incidence of shoulder arthroplasty is increasing dramatically for primary arthroplasty but also for revision arthroplasty. Revision to reverse total shoulder arthroplasty is increasingly the salvage operation for failed primary arthroplasty. The purpose of this review is to explore the indications for and results of revision reverse total shoulder arthroplasty. RECENT FINDINGS: Despite relatively high complication and reoperation rates with revision shoulder replacement, revision of failed hemiarthroplasty or total shoulder arthroplasty to reverse total shoulder arthroplasty improves outcomes for many patients. A failed hemiarthroplasty or total shoulder arthroplasty is frequently disabling for the patient and because the surgical revision options are often limited only to reverse total shoulder arthroplasty, the potential improvement is often worth the higher surgical complication or reoperation rate. Due to the challenges inherent in revision arthroplasty, revision of primary arthroplasty to reverse total shoulder arthroplasty, outcomes are poorer than primary reverse total shoulder arthroplasty. Despite these limitations, patient postoperative pain and function do increase from preoperative levels making conversion of hemiarthroplasty or anatomic total shoulder to reverse total shoulder arthroplasty an important option for a challenging problem.

Improving Our Ability to Predict Resident Applicant Performance: Validity Evidence for a Situational Judgment Test.

Construct: We investigated whether a situational judgment test (SJT) designed to measure professionalism in physicians predicts residents' performance on (a) Accreditation Council for Graduate Medical Education (ACGME) competencies and (b) a multisource professionalism assessment (MPA). Background: There is a consensus regarding the importance of assessing professionalism and interpersonal and communication skills in medical students, residents, and practicing physicians. Nonetheless, these noncognitive competencies are not well measured during medical education selection processes. One promising method for measuring these noncognitive competencies is the SJT. In a typical SJT, respondents are presented with written or video-based scenarios and asked to make choices from a set of alternative courses of action. Interpersonally oriented SJTs are commonly used for selection to medical schools in the United Kingdom and Belgium and for postgraduate selection of trainees to medical practice in Belgium, Singapore, Canada, and Australia. However, despite international evidence suggesting that SJTs are useful predictors of in-training performance, end-of-training performance, supervisory ratings of performance, and clinical skills licensing objective structured clinical examinations, the use of interpersonally oriented SJTs in residency settings in the United States has been infrequently investigated. The purpose of this study was to investigate whether residents' performance on an SJT designed to measure professionalism-related competencies-conscientiousness, integrity, accountability, aspiring to excellence, teamwork, stress tolerance, and patient-centered care-predicts both their current and future performance as residents on two important but conceptually distinct criteria: ACGME competencies and the MPA. Approach: We developed an SJT to measure seven dimensions of professionalism. During calendar year 2017, 21 residency programs from 2 institutions administered the SJT. We conducted analyses to determine the validity of SJT and USMLE scores in predicting milestone performance in ACGME core competency domains and the MPA in June 2017 and 3 months later in September 2017 for the MPA and 1 year later, in June 2018, for ACGME domains. Results: At both periods, the SJT score predicted overall ACGME milestone performance (r = .13 and .17, respectively; p < .05) and MPA performance (r = .19 and .21, respectively; p < .05). In addition, the SJT predicted ACGME patient care, systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism competencies (r = .16, .15, .15, .17, and .16, respectively; p < .05) 1 year later. The SJT score contributed incremental validity over USMLE scores in predicting overall ACGME milestone performance (ΔR = .07) 1 year later and MPA performance (ΔR = .05) 3 months later. Conclusions: SJTs show promise as a method for assessing noncognitive attributes in residency program applicants. The SJT's incremental validity to the USMLE series in this study underscores the importance of moving beyond these standardized tests to a more holistic review of candidates that includes both cognitive and noncognitive measures.

Outpatient and Semi-Outpatient Total Shoulder Replacement: Patient Selection and Program Management.

Shoulder arthroplasty has traditionally been viewed as an inpatient procedure because of the inherent medical comorbidities associated with an aging population and the need for postoperative pain control. Recent studies have shown that in appropriately selected patients, shoulder arthroplasty procedures can be safely done as outpatient procedures and can deliver economic value in today's cost-conscious health care environment. Several factors help ensure a successful surgical outcome, including cooperation from the ambulatory anesthesia service, proper patient selection, and perioperative pain control. Postoperatively, provider availability is vital to complete a seamless patient experience. With appropriate algorithms and care plans in place, outpatient shoulder arthroplasty can be a safe and cost-efficient procedure. The advances pioneered by outpatient shoulder arthroplasty will also serve to benefit inpatient shoulder arthroplasty patients via improved pain control, perioperative education, and potentially decreased length of stay.

Shoulder kinematics impact subacromial proximities: a review of the literature.

BACKGROUND: Alterations in glenohumeral and scapulothoracic kinematics have been theorized to contribute to rotator cuff pathology by impacting the magnitude of the subacromial space. OBJECTIVE: The purpose of this review is to summarize what is currently known about the relationship between shoulder kinematics and subacromial proximities. CONCLUSIONS: A variety of methods have been used to quantify subacromial proximities including photographs, MR imaging, ultrasonography, and single- and bi-plane radiographs. Changes in glenohumeral and scapulothoracic kinematics are associated with changes in subacromial proximities. However, the magnitude and direction of a particular motion's impact on subacromial proximities often vary between studies, which likely reflects different methodologies and subject populations. Glenohumeral elevation angle has been consistently found to impact subacromial proximities. Plane of humeral elevation also impacts subacromial proximities but to a lesser degree than the elevation angle. The impact of decreased scapulothoracic upward rotation on subacromial proximities is not absolute, but instead depends on the angle of humerothoracic elevation. The effects of scapular dyskinesis and humeral and scapular axial rotations on subacromial proximities are less clear. Future research is needed to further investigate the relationship between kinematics and subacromial proximities using more homogenous groups, determine the extent to which compression and other factors contribute to rotator cuff pathology, and develop accurate and reliable clinical measures of shoulder motion.