Toxin for Treating Raynaud Conditions in Hands (The TORCH Study): A Systematic Review and Meta-analysis.

Background: Raynaud disease of the hands is a complex disorder resulting in inappropriate constriction and/or insufficient dilation in microcirculation. There is an emerging role for botulinum toxin type A (BTX-A) in the treatment armamentarium for refractory Raynaud disease. The aim of this systematic review was to critically evaluate the management of primary and secondary Raynaud disease treated with BTX-A intervention. Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of clinical studies assessing treatment of primary or secondary Raynaud disease with BTX-A by searching Ovid MEDLINE and Embase databases from inception to first August 2023. The review protocol was prospectively registered on the PROSPERO database (CRD42022312253). Results: Our search strategy identified 288 research articles, of which 18 studies [four randomized controlled trials (RCTs), two non-RCTs, five case series, and seven retrospective cohort studies] were eligible for analysis. Meta-analysis demonstrated that the probability of pain visual analog scale score improvement with BTX-A intervention was 81.95% [95% confidence interval (74.12-87.81) P = 0.19, heterogeneity I 2 = 26%] and probability of digital ulcer healing was 79.37% [95% confidence interval (62.45-89.9) P = 0.02, heterogeneity I 2 = 56%]. Conclusions: Delivery of BTX-A to digital vessels in the hand may be an effective management strategy for primary and secondary Raynaud disease. A definitive, appropriately-powered RCT with objective functional and patient-reported outcome measures is required to accurately assess and quantify the efficacy of BTX-A in Raynaud disease of the hands.

Predictors of Bone Loss in Anterior Glenohumeral Instability.

BACKGROUND: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. RESULTS: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. CONCLUSION: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. REGISTRATION: NCT02075775 (ClinicalTrials.gov identifier).

Shoulder Arthrodesis.

Shoulder arthrodesis is an end-stage, salvage procedure for the glenohumeral joint and can provide a pain-free, stable shoulder with varying levels of function. Common indications include brachial plexus injury, chronic instability with rotator cuff and deltoid dysfunction, and failed shoulder arthroplasty. Multiple techniques are described, including intra-articular and extra-articular arthrodeses. Fusion can be accomplished with screw fixation, plate fixation, external fixation, and arthroscopic-assisted techniques. The optimal position of the arm is heavily debated in the literature, but the ideal position is thought to be 30° of flexion, 30° of abduction, and 30° of internal rotation. After successful fusion, the patient should be able to bring their hand to their mouth, reach their back pocket, and cross the midline for hygiene. Complications are not uncommon and include nonunion, malunion, fracture, and infection. With the increasing incidence of shoulder arthroplasty, failed arthroplasties are more commonly encountered. In a salvage situation, shoulder arthrodesis may be considered.

Avoiding Glenoid Baseplate Fixation Failure by Altering Surgical Technique for Varying Bone Densities.

Glenoid baseplate failure is one of the causes of revision and poor outcomes in reverse shoulder arthroplasty (RSA). The objective of this study was to determine whether alterations in surgical technique can improve time-zero fixation of the baseplate in varying bone densities. A secondary objective was to identify whether preoperative radiographic glenoid sclerosis width was associated with the implementation of these techniques. Methods: This study included a biomechanical analysis and a retrospective radiographic review. The biomechanical portion describes 2 alterations to the standard surgical technique (under-preparation [A1] or over-preparation [A2] of the central screw pilot hole) and determined their torque-compression relationship via bone-substitute blocks with varying densities. Patients who underwent the described technical alterations were identified from a registry database of primary RSAs performed between 2007 and 2020. These patients were matched to patients who underwent the standard surgical technique, and preoperative radiographs were compared. Interrater reliability testing was performed to determine reproducibility. Results: With respect to the biomechanical arm, the average compressive force of the baseplate in the low-density block model when using the standard technique was 112 N compared with 300 N for the A1 technique (p = 0.01). In the high-density bone model, the standard technique resulted in failure to seat the baseplate, or screw breakage. Performing the A2 technique, the baseplate was seated without failure, with an average compressive force of 450 N. In the clinical arm, retrospective intraoperative video review for use of the alternative techniques found 20 shoulders in the "low-density" cohort and 21 in the "high-density" cohort. There was a significant difference in the glenoid sclerosis thickness between the experimental and matched control groups in our "high-density" cohort (p = 0.0014). The interrater reliability coefficient was found to be 0.69 for the "low-density" glenoid sclerosis thickness measurement and 0.92 for the "high-density" measurement. Conclusions: In low- and high-density bone models, alterations in surgical technique significantly improved compression and improved the ability to successfully seat the glenoid baseplate. Preoperative radiographs can assist in indicating the alternative technique in the sclerotic glenoid. Clinical Relevance: Utilization of these techniques intraoperatively will improve time-zero fixation of the glenoid baseplate and potentially avoid failure of fixation.

Total shoulder arthroplasty using an inlay glenoid component for glenoid deficiency: mid- to long-term follow-up of a previously published cohort.

BACKGROUND: The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients. METHODS: We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores. RESULTS: Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P < .001]; external rotation, 18.8° [P < .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P < .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively. CONCLUSION: Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Outcomes of instability after reverse shoulder arthroplasty: reoperation and persistent instability are common.

HYPOTHESIS: Although risk factors for instability after reverse shoulder arthroplasty (RSA) have been extensively studied, the outcomes of patients who experience instability are unknown. The purpose of this study was to evaluate functional outcomes in patients with instability after RSA. METHODS: We retrospectively identified patients with instability after RSA with a minimum of 2 years' follow-up from an institutional database. Baseline data were recorded, and all patients we contacted to obtain clinical outcome scores. Patients who required revision surgery and those treated successfully with closed reduction were compared. RESULTS: Fifty patients were included. Of these patients, 40 (80%) required revision surgery whereas 10 (20%) were treated successfully with closed reduction. At an average follow-up of 63.7 months (range, 24-123 months), outcome scores did not differ between groups. Patients who required revision surgery were more likely to have undergone previous shoulder surgery, prior to their index arthroplasty (P = .031). Seventeen patients (42.5%) reported recurrent instability following revision surgery, and 14 (35.0%) required additional revision surgery. Ultimately, stability was never achieved in 7 of 50 patients (14%) after their index instability event. CONCLUSION: Although instability after RSA can commonly be corrected with reasonable functional results, multiple procedures may be needed and some patients may experience persistent instability.

Improved mechanical fixation of an all-polyethylene glenoid reduces postoperative radiolucent lines.

BACKGROUND: The rationale for advances in implant design is to improve performance in comparison to their predecessors. The purpose of this study was to compare a newer, self-pressurizing peripheral peg glenoid to a traditional polyethylene pegged glenoid through biomechanical evaluation and a retrospective radiographic and clinical review. METHODS: Three testing conditions (uncemented, partially cemented, and fully cemented) were chosen to assess the 2 component designs in a foam block model. The number of hammer hits to seat the component, amount of time to seat the component, and resistance-to-seat were collected. The implants were then cyclically loaded following ASTM F2028-17 testing standard. Clinically, postoperative radiographs of patients with a self-pressurized glenoid component (n = 225 patients) and traditional glenoid component (n = 206 patients) were evaluated for radiolucent lines and glenoid seating at various timepoints. Clinical outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, and visual analog scale pain scores) and complications were recorded. The presence of radiolucent lines at the bone-cement interface was evaluated using the Modified Franklin Grade and the Lazarus grade. RESULTS: The self-pressurizing glenoid design required significantly more hammer hits than traditional glenoid designs in all groups tested (P < .029). Moreover, the self-pressurizing design had significantly more resistance-to-seat than traditional components in both the uncemented and partially cemented group (P < .002). No difference in resistance-to-seat was found between designs in the fully cemented group. The uncemented and partially cemented groups did not survive the full 50,000 cycles; however the self-pressurizing design had significantly less motion than the traditional design (P < .001). No differences between component designs were found in the fully cemented group at 50,000 cycles. The self-pressurizing glenoid component had 0.005% radiographic radiolucent lines, and the traditional glenoid component had 45% radiographic radiolucent lines, with 38% of the radiolucencies in the traditional glenoid component group being defined as grade E. There were no progressive radiolucencies, differences in clinical outcomes, or complications at 2 years postoperatively. CONCLUSION: In the fully cemented condition, the 2 component designs had comparable performance; however, the differences in designs could be better observed in the uncemented group. The self-pressurizing all-polyethylene design studied has superior biomechanical stability. Clinically, the improved stability of the glenoid component correlated with a reduction of radiolucent lines and will likely lead to a reduction in glenoid component loosening.

Ambulatory shoulder arthroplasty provides a mild reduction in overall cost compared with inpatient shoulder arthroplasty cost of ambulatory shoulder arthroplasty.

HYPOTHESIS: The purpose of this study was to determine the relative cost difference of inpatient vs. ambulatory total shoulder arthroplasty (TSA) procedures. METHODS: A retrospective case series was performed to identify a consecutive series of patients who underwent primary anatomic or reverse TSA at 2 orthopedic specialty hospitals between September 2015 and August 2020. Those undergoing surgery for fracture or revision were excluded. Itemized facility costs were analyzed with a time-driven activity-based costing model and compared between ambulatory and non-ambulatory procedures. Ambulatory patients were defined as those admitted and discharged on the same calendar day. All other patients were considered non-ambulatory. RESULTS: A total of 1027 patients were analyzed, comprising 38 ambulatory patients (3.7%) and 989 non-ambulatory patients (96.3%). There was a higher proportion of anatomic TSA than reverse shoulder arthroplasty in the ambulatory group (81.6% vs. 51.7%, P < .0001). Overall, there was no difference in cost between the 2 groups ($8832 vs. $8841, P = .97). However, personnel costs were greater in the non-same-day group ($1895 vs. $2743, P < .0001) whereas supply costs were less ($6937 vs. $6097, P < .0003). When implant costs were excluded, outpatient shoulder arthroplasty provided a cost savings of $745. CONCLUSION: Ambulatory shoulder arthroplasty provides a mild cost savings of $745 after controlling for fixed costs. This is much less dramatic than previously reported and should raise concern as shoulder arthroplasty continues to be targeted by payers as a potential for cost savings through decreased reimbursement.

Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component.

HYPOTHESIS: The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component. METHODS: Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation. RESULTS: Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment. CONCLUSION: Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

PURPOSE: To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE: I, prognostic study.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

HYPOTHESIS: The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments. RESULTS: After full-text review of 490 articles, 74 articles met all inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluation score was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data. CONCLUSION: Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.

Paediatric Dupuytren's Disease in a Child of Indian Ethnicity: A Case Report and Literature Review.

Paediatric Dupuytren's disease is a very rare clinical entity. Dupuytren's disease has preponderance to older males of Celtic heritage. We present a case of Dupuytren's disease in an eight-year-old boy of Indian ethnicity who presented with a progressive flexion contracture of his right ring finger for a duration of six months. On examination, he had an isolated 60-degree flexion contracture of the proximal interphalangeal joint with thickening of the skin and subcutaneous tissues. This was consistent with Dupuytren's cord and contracture. He proceeded to theatre for a dermofasciectomy, with subsequent histological confirmation of Dupuytren's disease. We performed a review of the literature and identified 21 reported cases of Dupuytren's disease affecting the hand in the paediatric population. This is a rare report of Dupuytren's disease affecting a child of Indian ethnicity.

Free Vascularized Rectus Abdominis Transfer With Pedicled Intercostal Innervation for Functional Reconstruction of the Elbow in Total Brachial Plexus Palsy.

PURPOSE: Reanimation of palsied upper limbs usually follows an escalating pattern of nerve repair, nerve transfers, and musculotendinous transfers and culminates in free functioning muscle transfers. When there are no other musculotendinous options, we explored the possibility of transferring the rectus abdominus to the biceps by maintaining the nerve pedicle but dividing the vascular pedicle and anastomosing it to the brachial artery. METHODS: We performed anatomical dissection of the nerve and blood supply of 6 rectus abdominis muscles in 3 cadavers. A retrospective analysis of 4 patients in whom a rectus abdominus muscle transfer with a pedicled nerve, but free vascular supply, was then performed. RESULTS: The anatomical feasibility study demonstrated that it was possible to elevate the rectus abdominis on its intercostal nerve supply to the midaxillary line, allowing the muscle to be pedicled on its nerve supply and be transferred to the arm to reconstruct biceps. The vascular supply could be reestablished by anastomosis of inferior epigastric vessels to the brachial artery and veins. In 4 patients, elbow flexion strength of M3 or greater was achieved. Average elbow range of dynamic flexion was 120° (range, 92° to 131°). Shoulder stability and external rotation improved in all patients with resolution of shoulder subluxation. Two patients developed donor site hernias requiring mesh reconstruction. Complications included a hypertrophic recipient site scar in one patient, and recipient site wound dehiscence in another. CONCLUSIONS: Rectus abdominus can be transferred to reconstruct elbow flexion when other musculotendinous transfers are unavailable and as an alternative to free functioning muscle transfer. However, rectus abdominus transfer still requires microsurgical skills for the vessel anastomoses. This is an effective procedure for functional reconstruction of the elbow and adds to the armamentarium in the management of brachial plexus pathology when other transfers are unavailable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Increased Health Care Costs and Opioid Use in Patients with Anxiety and Depression Undergoing Rotator Cuff Repair.

PURPOSE: To (1) quantify the prevalence of mood disorders in patients undergoing arthroscopic rotator cuff repair (RCR) by use of a large claims database and (2) compare opioid use and medical costs in the year before and the year after RCR between patients with and without comorbid mood disorders. METHODS: A large claims database was queried to identify patients who underwent arthroscopic RCR (Current Procedural Terminology code 29827) between October 2010 and December 2015. All patients were then screened for insurance claims relating to either anxiety or depression. We compared net costs and opioid use both 1 year preoperatively and 1 year postoperatively between patients with and without mood disorders by use of an analysis of covariance. RESULTS: A total of 170,329 patients (97,427 male patients [57.2%] and 72,902 female patients [42.8%]) undergoing arthroscopic RCR were identified. Of the 170,329 patients, 46,737 (27.4%) had comorbid anxiety or depression, and after adjustment for preoperative cost, sex, age, and both preoperative and postoperative opioid use, the 1-year postoperative cost was 7.05% higher for those with a preoperative mood disorder than for those without a mood disorder. In addition, opioid use both in the 180 days prior to surgery (36.7% vs 26.9%) and more than 90 days after surgery (33.0% vs 27.2%) was substantially greater in the group with comorbid depression or anxiety. CONCLUSIONS: In patients with comorbid mood disorders, opioid use and health care costs were increased both preoperatively and postoperatively. The increased cost in this patient population is estimated at $62.3 million annually. In an effort to provide high-quality, value-based care, treatment strategies should be developed to identify these patients preoperatively and provide the appropriate resources needed to improve the probability of a successful surgical outcome. LEVEL OF EVIDENCE: Level III, retrospective, comparative therapeutic study.

Antibiotic cement spacer retention for chronic shoulder infection after minimum 2-year follow-up.

HYPOTHESIS: The treatment of periprosthetic shoulder infections and proximal humerus osteomyelitis is challenging. The outcomes of antibiotic cement spacer retention are poorly defined in the literature. The purpose of this study was to review long-term functional and patient-reported outcomes data of patients with retained antibiotic cement spacers. We predict reasonable functional outcomes and minimal pain. METHODS: We identified 22 patients of the senior author who have been treated with definitive antibiotic spacer placement. All patients were originally offered a 2-stage revision and declined. Twelve patients had a minimum follow-up of 2 years and were included in our cohort. Mean age was 70.7 (range 59-81), 8/12 patients were female, and the average body mass index was 27.8 (range = 17-45). Functional outcome assessments included the Standardized Shoulder Assessment Form, the Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and visual analog scale (VAS) along with clinical range of motion examination. RESULTS: The patients were followed up for a mean of 5.6 years. Eight patients had spacer placement for chronic shoulder arthroplasty infections, whereas 4 patients had spacer placement for chronic osteomyelitis of the proximal humerus. No patients were currently being treated with suppressive antibiotics. One patient had negative cultures at the time of antibiotic spacer placement. The most common organisms were Cutibacterium acnes (6), Staphylococcus epidermidis (6), and methicillin-resistant Staphylococcus aureus (4), with 4 patients growing more than 1 species. The average ASES score was 54 (range = 27-73), QuickDASH was 45 (range = 14-89), and VAS score 2.8 (range = 0-8). Average active range of motion was 68° of forward elevation and 35° of external rotation. CONCLUSIONS: Retention of antibiotic cement spacer is a viable option in the treatment algorithm for chronic shoulder infections. Long-term antibiotic cement spacer may be considered for those patients who are unwilling or unable to undergo a 2-stage revision. Patients can expect a reasonable amount of function and little to no pain with an antibiotic cement spacer.

Surgical outcomes in the Frequency, Etiology, Direction, and Severity (FEDS) classification system for shoulder instability.

BACKGROUND: The Frequency, Etiology, Direction, and Severity (FEDS) system was developed as a simple but reliable method for classifying shoulder instability based on 4 factors attainable by history and physical examination: frequency (solitary, occasional, or frequent); etiology (traumatic or atraumatic); direction (anterior, posterior, or inferior); and severity (subluxation or dislocation). This study investigated the epidemiology and 2-year surgical outcomes for the FEDS categories in the prospective Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. METHODS: At the time of surgery, 1204 patients were assigned to the FEDS categories. Follow-up data were available for 636 of 734 patients (86.6%) who had undergone surgery at least 2 years prior to analysis. The most common categories were further analyzed by patient-reported outcomes (PROs) (American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability index, Single Assessment Numeric Evaluation scores) and rates of recurrent subluxation, recurrent dislocation, and revision surgery. RESULTS: Of the 36 FEDS categories, 16 represented at least 1% of patients. Occasional traumatic anterior dislocation (OTAD) was the most common category, with 16.4% of patients. Five other anterior categories (solitary traumatic anterior subluxation, occasional traumatic anterior subluxation [OTAS], frequent traumatic anterior subluxation [FTAS], solitary traumatic anterior dislocation, and frequent traumatic anterior dislocation) and one posterior category (solitary traumatic posterior subluxation [STPS]) represented at least 5% of patients. PROs improved significantly for each category. The highest rates of recurrent subluxation occurred in FTAS, OTAS, and OTAD cases; dislocation, OTAS and FTAS cases; and further surgery, OTAD cases. The lowest rates of failure occurred in STPS cases. Downward trends in PROs and higher failure rates were noted with an increasing number of preoperative dislocations. CONCLUSION: Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. Overall, outcomes decreased with a higher number of preoperative dislocations.

The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

BACKGROUND: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain. RESULTS: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; P < .001) and were more likely to be female (25.3% vs 17.4%; P = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) (P < .001), more frequent depression (22.2% vs 8.3%; P < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) (P < .01), and worse preoperative expectations (P < .01). CONCLUSION: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes.

Are Routine Postoperative Computer Tomography Scans Warranted for All Patients After Operative Fixation of Pelvic Ring Injuries?

OBJECTIVE: To evaluate the efficacy of routine postoperative computed topography (CT) scan after percutaneous fixation of unstable pelvic ring injuries. DESIGN: Retrospective chart review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 362 consecutive patients underwent operative fixation of unstable pelvic ring injuries during the study period. INTERVENTION: Postoperative CT scan of the pelvis was obtained in 331 (91%) of the 362 patients treated operatively for unstable pelvic ring injuries. MAIN OUTCOME MEASUREMENTS: Revision surgery based on routine postoperative CT scan. RESULTS: Two patients (0.55%) returned to the operating room on the basis of postoperative CT scans due to malpositioned implants. There were no significant differences of age, sex, body mass index, Injury Severity Score, mechanism of injury, smoking status, or diabetes status between those who did and did not undergo revision surgery. A dysmorphic pelvis was identified in 154 (47%) patients. Both patients undergoing revision surgery were determined to have a dysmorphic pelvis while no patients with normal pelvic anatomy returned to the operating room based on postoperative CT (2/154, 1.3% vs. 0/177, 0%, P = 0.22). CONCLUSIONS: Although there remains a role for postoperative CT scans in the appropriately selected patient, in the hands of experienced orthopaedic traumatologists, patients with adequate intraoperative fluoroscopy and a nondysmorphic pelvis may not require routine postoperative three-dimensional imaging. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sex-related differences in patients undergoing surgery for shoulder instability: a Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort study.

HYPOTHESIS AND BACKGROUND: Male sex has been identified as a risk factor for both primary shoulder dislocation and recurrent instability, and male patients more often undergo surgery for instability. Despite published discrepancies between sexes regarding the incidence and surgical rates of shoulder instability, there is little detail on the differences in presentation, mechanism of injury, and intraoperative findings. The purpose of this study was to explore these differences. METHODS: Prospective baseline data from 1010 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed for sex-related differences using demographic characteristics, patient-reported outcomes, radiographic findings, intraoperative findings, and surgical procedures performed. Two-tailed t tests and χ2 tests were used to compare the continuous and categorical data, respectively. Patients were categorized using the Frequency, Etiology, Direction, Severity (FEDS) classification system. RESULTS: Male patients comprised 81.3% of the cohort. Male patients had a significantly higher rate of traumatic instability and rate of initial instability while playing sports, as well as significantly higher activity scores. Female patients had significantly lower preoperative American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability Index, 36-Item Health Survey, and Single Assessment Numeric Evaluation scores. No difference in the number of dislocations was found between male and female patients. Intraoperatively, male patients had higher rates of labral pathology and bone loss whereas female patients had higher rates of capsular laxity. These differences resulted in more Latarjet procedures for male patients and more soft-tissue procedures for female patients. CONCLUSION: There are differences between male and female patients in the etiology of their instability, baseline patient-reported outcomes, and associated shoulder pathology, likely reflecting intrinsic and activity-related variation. These differences may influence clinical decision making and patient outcomes.

Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability.

HYPOTHESIS: The purpose of this multicenter epidemiologic study was to determine the distribution of patients within the Frequency, Etiology, Direction, and Severity (FEDS) classification system to determine which categories are of clinical importance. METHODS: Shoulder instability patients were identified using International Classification of Diseases, Ninth Revision coding data from 3 separate institutions from 2005-2010. Data were collected retrospectively. Details of instability were recorded in accordance with the FEDS classification system. Each patient was assigned a classification within the FEDS system. After all patients were assigned to a group, each group was individually analyzed and compared with the other groups. RESULTS: There are a total of 36 possible combinations within the FEDS system. Only 16 categories were represented by at least 1% of our patient population. Six categories captured at least 5% of all patients with shoulder instability. Only 2 categories represented greater than 10% of the population: solitary, traumatic, anterior dislocation, with 95 patients (24.8%), and occasional, traumatic, anterior dislocation, with 63 patients (16.4%). CONCLUSIONS: There are 16 categories within the FEDS classification that are clinically significant. Solitary, traumatic, anterior dislocation and occasional, traumatic, anterior dislocation were the most frequently observed in our cohort.