Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations.

Background: The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods: A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results: Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion: The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

Tendon Transfers in Reverse Total Shoulder Arthroplasty: A Systematic Review.

PURPOSE: The purpose of this study was to evaluate clinical outcomes after tendon transfers in the setting of reverse total shoulder arthroplasty (RTSA). METHODS: PubMed and Embase were searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to find primary clinical studies of any type of tendon transfer in the setting of RTSA. RESULTS: Overall, 17 studies (level of evidence [LOE] I: 1, LOE II: 0, LOE III: 3, LOE IV: 13) met inclusion criteria, with 300 shoulders. Most patients were female (56.7%), with an average age of 68.7 years (range 19 to 89) and a mean follow-up of 46.2 months (range 6 to 174). 11 studies reported outcomes after combined latissimus dorsi and teres major transfer (LDTM) while eight studies reported on latissimus dorsi transfer only (LD). Improvements in commonly reported subjective and functional outcome measures were as follows: external rotation +32° (LDTM) and +30° (LD), flexion +65° (LDTM) and +59° (LD), Visual Analog Score -5.4 (LDTM) and -4.5 (LD), subjective shoulder value +43.8% (LDTM) and +46.3% (LD), and overall Constant score +33.8 (LDTM) and +38.7 (LD). The overall complication rate was 11.3%, including tendon transfer ruptures (0.7%), instability (3.0%), infection (2.0%), and nerve injury (0.3%). The all-cause repeat operation rate was 7.3%, most commonly for arthroplasty revision (5.3%). Subgroup analysis revealed that lateralized implants with tendon transfer resulted in markedly greater improvements in Constant score, flexion, ER1, and ER2 while medialized implants with tendon transfer had markedly greater improvements in Visual Analog Score, subjective shoulder value, and abduction. CONCLUSION: Patients undergoing tendon transfer of either combined LDTM or latissimus dorsi alone in the setting of RTSA have markedly improved subjective and functional outcomes. A moderate incidence of complications (11.3%) was noted in this patient population.

Recent Advances in the Design and Application of Shoulder Arthroplasty Implant Systems and Their Impact on Clinical Outcomes: A Comprehensive Review.

Purpose of Review: This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions. Recent Findings: The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA's 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations. Summary: Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.

Single Shot Interscalene Block with Liposomal Bupivacaine versus Non-Liposomal Bupivacaine in Shoulder Arthroplasty.

BACKGROUND: Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including non-liposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of the current of study was to compare pain control and opioid consumption within 48 hours postoperative in those undergoing TSA with either LIB or NLIB. METHODS: This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or a NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day ED visits or readmissions. The primary outcome was postoperative pain and opioid use. RESULTS: Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (p>0.05 for all). However, the LIB group had improved pain scores at 24- and 36-hours postoperative (p<0.05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 NRS-11 score, between the two anesthesia groups after adjusting for preoperative pain and baseline opioid use (OR: 1.25; 95% CI: 0.57-2.74; p=0.57). Overall, 99/316 (31.3%) of patients receiving LIB did not require any postoperative opioids compared with 38/173 (22.0%) receiving NLIB; however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (p=0.33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (p>0.05 for both). Finally, no significant differences in 30- and 90-day ED visits or readmission rates were found (all p>0.05). CONCLUSION: LIB and NLIB demonstrated differences in patient reported pain scores at 24- and 36-hours post operation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.

Identification of ChatGPT-Generated Abstracts Within Shoulder and Elbow Surgery Poses a Challenge for Reviewers.

PURPOSE: To evaluate the extent to which experienced reviewers can accurately discern between AI-generated and original research abstracts published in the field of shoulder and elbow surgery and compare this to the performance of an AI-detection tool. METHODS: Twenty-five shoulder and elbow-related articles published in high-impact journals in 2023 were randomly selected. ChatGPT was prompted with only the abstract title to create an AI-generated version of each abstract. The resulting 50 abstracts were randomly distributed to and evaluated by 8 blinded peer reviewers with at least 5 years of experience. Reviewers were tasked with distinguishing between original and AI-generated text. A Likert scale assessed reviewer confidence for each interpretation and the primary reason guiding assessment of generated text was collected. AI output detector (0-100%) and plagiarism (0-100%) scores were evaluated using GPTZero. RESULTS: Reviewers correctly identified 62% of AI-generated abstracts and misclassified 38% of original abstracts as being AI-generated. GPTZero reported a significantly higher probability of AI output among generated abstracts (median 56%, IQR 51-77%) compared to original abstracts (median 10%, IQR 4-37%; p < 0.01). Generated abstracts scored significantly lower on the plagiarism detector (median 7%, IQR 5-14%) relative to original abstracts (median 82%, IQR 72-92%; p < 0.01). Correct identification of AI-generated abstracts was predominately attributed to the presence of unrealistic data/values. The primary reason for misidentifying original abstracts as AI was attributed to writing style. CONCLUSIONS: Experienced reviewers faced difficulties in distinguishing between human and AI-generated research content within shoulder and elbow surgery. The presence of unrealistic data facilitated correct identification of AI abstracts, whereas misidentification of original abstracts was often ascribed to writing style.

Defining Pseudoparalysis & Pseudoparesis - A Consensus Study.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. METHODS: A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion (ROM) should be unaffected, the passive range of abduction should not be considered and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by ROM rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. CONCLUSION: A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of RCTs. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Risk Factors for Recurrence Following Arthroscopic Bankart Repair - A Systematic.

BACKGROUND: Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. PURPOSE: To systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair. METHODS: A literature search was performed using the PubMed/Medline databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair. RESULTS: Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2,750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a two-fold recurrence rate of 27.0% (171/634) for patients under 20 years old compared to 13.3% (197/1485) for older patients (p<0.001). Seventeen studies completed multivariable analysis, 13 of which were significant (Odds Ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found OR ranging from 0.7-35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29/156) risk of recurrence with 2 anchors compared to 18.1% (89/491) with 3 or more anchors (p=0.06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant SLAP tear (0%). CONCLUSION: Younger age, glenoid bone loss, and off-track Hill-Sachs lesions, are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

Outcomes of Arthroscopic Stabilization for Posterior Shoulder Instability - A Systematic Review.

BACKGROUND: Posterior shoulder instability makes up approximately 10% of all shoulder instability cases and its diagnosis and treatment is less well understood. Recently, however, there has been increased recognition of posterior instability and posterior stabilization. The purpose of this study was to systematically review the literature to ascertain the outcomes on arthroscopic stabilization of posterior shoulder instability. METHODS: Two independent reviewers conducted a systematic literature search based on PRISMA guidelines, utilizing the MEDLINE database. Studies were eligible for inclusion if they reported postoperative outcomes for posterior shoulder instability following arthroscopic stabilization. RESULTS: A total of 48 studies met inclusion criteria for review including 2307 shoulders. Majority of patients were male (83.3%), with an average age of 26.1 years and a mean follow-up of 46.8 months. The functional outcome score primarily utilized for postoperative assessment was ASES with an average of 84.77. Overall, 90.9% of patients reported being satisfied with their arthroscopic stabilization. Recurrent instability occurred in 7.4% of patients. The total revision rate was 5.2%. 16.6% of patients reported residual pain postoperatively. The rate of return to play was 86.4% with 68.0% of patients returning to play at the same or higher level of play. CONCLUSION: Arthroscopic stabilization of posterior shoulder instability resulted in good outcomes with high patient satisfaction and low rates of recurrent instability, revisions, and residual pain.

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain. CONCLUSIONS: The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired. LEVEL OF EVIDENCE: Level V, expert opinion.

Outcomes and complications of revision reverse shoulder arthroplasty after failed primary anatomic shoulder arthroplasty or hemiarthroplasty: a systematic review.

BACKGROUND: The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, range of motion (ROM), and complication and reoperation rates after revision reverse shoulder arthroplasty (RSA) for a failed primary total shoulder arthroplasty (TSA) or hemiarthroplasty (HA). METHODS: Two independent reviewers performed the literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Studies were included if they reported clinical outcomes for revision RSA for a failed primary TSA or HA. RESULTS: Our review found 23 studies including 1041 shoulders (627 TSA and 414 HA) meeting our inclusion criteria. The majority of patients were female (66.1%), with an average age of 69.0 years (range: 39-93 years) and a mean follow-up of 46.3 months. American Shoulder and Elbow Surgeons and visual analog scale pain scores improved from 32.6 to 61.9 and 6.7 to 2.7, respectively. ROM results include forward flexion, abduction, and external rotation, which improved from 59.4° to 107.7°, 50.7° to 104.4°, and 19.8° to 26.3°, respectively. Only 1 of the 10 studies reporting internal rotation found a statistically significant difference, with the mean internal rotation improving from S1-S3 preoperatively to L4-L5 postoperatively for patients undergoing HA. The overall complication rate and reoperation rate were 23.4% and 12.5%, respectively. The most common complications were glenoid component loosening (6.0%), fracture (periprosthetic, intraoperative, or other scapula fractures) (n = 4.7%), and infection (n = 3.3%). CONCLUSIONS: Revision RSA for a failed primary TSA and HA has been shown to result in excellent functional outcomes and improved ROM, suggesting that patients who have failed TSA or HA may benefit from a revision RSA.

Clinical Outcomes in Prospective versus Retrospective Studies on Arthroscopic Bankart Repair: A Systematic Review.

BACKGROUND: The majority of the current literature on arthroscopic Bankart repair is retrospective and discrepancies exist regarding clinical outcomes including recurrent instability and return to play amongst studies of different levels of evidence. PURPOSE: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100. A chi-square test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies. RESULTS: One hundred ninety-three studies were included in the analysis with 53 prospective studies and 140 retrospective in design. Encompassing a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of re-dislocation in the prospective studies was 8.0% vs. 5.9% in retrospective (p < 0.001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective (p = 0.004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (p = 0.013) There was no significant difference in terms of overall rate to return to play in prospective and retrospective studies was 90% and 91%, respectively (p=0.548). The overall rate of complications in the prospective cohort was 0.27% and 0.78% in the retrospective studies (p = 0.002). CONCLUSION: The overall rates of recurrent dislocations, subluxations are higher in prospective studies compared to retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.

Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS: The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE: Level V, expert opinion.

Type V superior labrum anterior to posterior repair: a systematic review.

BACKGROUND: The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following type V superior labrum anterior to posterior (SLAP) repair. METHODS: Two independent reviewers performed a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, utilizing the EMBASE, MEDLINE, and the Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of <.05 was considered to be statistically significant. RESULTS: Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were males (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean American Shoulder and Elbow Surgeons score was 88.3, the mean subjective shoulder value score was 85.5%, and the mean visual analog scale pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in visual analog scale pain scores (mean difference; 0.15, 95% confidence interval, -0.13 to 0.44, I2 = 0%, P = .29) and recurrence rates (risk ratio; 1.38, 95% confidence interval, 0.88-2.15, I2 = 0%, P = .16). CONCLUSION: Arthroscopic repair of type V SLAP tears results in excellent functional outcomes, with high return to play rates in athletes. There are low rates of reoperations and recurrent dislocations. Additionally, in comparison to an isolated Bankart repair, SLAP repair does not increase recurrence rates or postoperative pain.

Utility of superior augments in reverse shoulder arthroplasty (Exactech, Equinoxe GPS) without significant glenoid deformity.

BACKGROUND: Superior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal was to compare superior augments vs. no-augment baseplates in reverse shoulder arthroplasty (RSA) for patients with rotator cuff dysfunction and no significant superior glenoid erosion. METHODS: A multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Equinoxe GPS; Exactech) and 3-year follow-up (mean 32 months' follow-up, range 20-61 months) who had preoperative superior inclination less than 10° and retroversion less than 15°. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to 3 years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. χ2 test was used to compare categorical variables, and Student t test was used to compare the augment and no-augment cohorts. RESULTS: The study population consisted of 54 superior augment patients and 91 no-augment patients. The augment cohort had lower body mass index (27.2 vs. 29.4, P = .023) and higher native superior inclination (5.9° vs. 1.4°, P < .001). No difference between the augment and no-augment cohorts was found regarding age (P = .643), gender (P = .314), medical comorbidities (P > .05), surgical indication (P = .082), and native glenoid version (P = .564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, P = .023), and all remaining range of motion (ROM) and patient-reported outcomes (PROs) preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative Shoulder Arthroplasty Smart score was significantly higher (78.0 vs. 73.6, P = .042), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score trended toward higher (83.6 vs. 77.5, P = .063) in the augment cohort. The augment cohort had a significantly lower proportion of patients who planned to have superior baseplate tilt (1.9% vs. 14.3%, P = .012) and had greater mean inclination correction (6.3° vs. 1.3°, P < .001), compared with the no-augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no-augment cohorts (5.6% vs. 3.3%, P = .509). DISCUSSION: Superior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared with nonaugmented baseplates at the 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity.

Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Long-term outcomes of anterior shoulder instability treated with open latarjet procedure - a systematic review of outcomes at a minimum 15-year follow-up.

Background: To systematically review the literature to evaluate the outcomes following an open Latarjet (OL) procedure at a minimum 15-year follow-up. Methods: Two independent reviewers performed a literature search using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using 3 databases. Only studies reporting outcomes of OL procedure with a minimum of 15 years of follow-up were included. Results: Nine studies composed of 326 shoulders (78.2% males) in 313 patients were included (average age 26.9 ± 3.2 years (15-58)), with a mean follow-up of 271.9 ± 69.2 months (180-420) At a minimum 15-year follow-up, 93.5% (286 of 306) patients reported being satisfied with their OL procedure, whilst 86.8% (177 of 204) reported good/excellent outcomes at final follow-up. All nine of the included studies reported an overall rate of recurrent instability was 7.7%, with re-dislocations and subluxation at 3.4% and 5.8%, respectively. The rate of surgical revision was 5.15%; 3.5% of cases were revised for recurrent instability. Instability arthropathy was reported across all included studies as 41.0%. Conclusion: The OL procedure results in satisfactory clinical outcomes, low rates of recurrent instability and surgical revision at a minimum 15-year follow-up. Although high levels of radiological instability arthropathy and residual pain are found over the same period, these appear stable from a minimum of 10-year follow-up data. Level of Evidence: IV; a systematic review of all levels of evidence.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review.

Background: The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability. Methods: A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure. Results: There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play. Discussion: Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Comparison of Low-Dose Computed Tomography Versus Conventional-Dose Computed Tomography in the Evaluation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making. METHODS: A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images. RESULTS: A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers. CONCLUSION: This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging.

Bone Marrow Stimulation for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Bone marrow stimulation (BMS) has been proposed to augment healing at the time of arthroscopic rotator cuff repair (ARCR) by creating several bone marrow vents in the footprint of the rotator cuff, allowing mesenchymal stem cells, platelets, and growth factors to cover the area as a "crimson duvet." PURPOSE: To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes after BMS and a control for those undergoing ARCR. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: A literature search of 3 databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing BMS and a control for ARCR were included. Clinical outcomes were compared, and a P value <.05 was considered to be statistically significant. RESULTS: A total of 7 RCTs with 576 patients were included. Overall, 18.8% of patients treated with BMS and 21.0% of patients treated with a control had a retear (I2 = 43%; P = .61). With BMS, the mean Constant score was 88.2, and with the control, the mean Constant score was 86.7 (P = .12). Additionally, there was no significant difference in the American Shoulder and Elbow Surgeons score (94.3 vs 93.2, respectively; P = .31) or visual analog scale score (0.9 vs 0.9, respectively; P = .89). CONCLUSION: The level 1 evidence in the literature did not support BMS as a modality to improve retear rates or clinical outcomes after ARCR.

Tranexamic Acid for Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference. PURPOSE: To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing TXA with a control in ARCR were included. Visualization, postoperative pain, operative time, pump pressures, and shoulder swelling were evaluated. A P value < .05 was deemed statistically significant. RESULTS: Six RCTs with 450 patients were included in this review. Overall, 5 studies evaluated intraoperative visualization, with 3 studies finding a significant difference in favor of TXA. With TXA, patients had a lower mean postoperative visual analog scale (VAS) score of 3.3, and with the control, patients had a mean VAS score of 4.1, which was statistically significant (P = .001). With TXA, the mean weighted operation time was 79.3 minutes, and with the control, the mean operation time was 88.8 minutes, which was statistically significant (P = .001). No study found any difference in intraoperative pump pressures or swelling. CONCLUSION: TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR.