How Prominent Are Gender Bias, Racial Bias, and Score Inflation in Orthopaedic Surgery Residency Recommendation Letters? A Systematic Review.

INTRODUCTION: Letters of recommendation are considered an important factor in the holistic ranking of orthopaedic residency applications. The standardized letter of recommendation (SLOR) was introduced in 2017 in response to the inherent bias and limited comparative value of traditional LORs. It includes standardized questions about an applicant's orthopaedic qualifications, designed to enable fair comparisons among candidates. However, disparate and inconsistent findings have made it difficult to draw meaningful conclusions from individual studies on the SLOR and narrative letter of recommendation. QUESTION/PURPOSES: In this systematic review we asked: (1) What is the distribution of applicant SLOR rating among nine domains and summative scores? (2) Are there applicant characteristics associated with SLOR ratings? (3) Is there gender and racial bias in the SLOR and narrative letter of recommendation? METHODS: PubMed, EBSCO, and Google Scholar electronic databases were queried on March 20, 2023, to identify all studies evaluating SLOR and narrative letter of recommendations between January 1, 2017, and March 20, 2023. Articles that evaluated orthopaedic SLOR or narrative LORs were included. Systematic reviews, case reports, duplicate studies between databases, and grey literature such as abstracts and articles on preprint servers were excluded. Eight studies including 6179 applicants and 18,987 letters of recommendation were included in the final analysis. The applicant classes ranged from years 2014 to 2020. Two reviewers independently evaluated the quality of the included studies using the Joanna Briggs Institute (JBI) tool for cross-sectional studies. The mean JBI score of included studies was 7.4 out of a maximum of 8, with higher scores indicating better quality. The primary outcome was to determine the distribution of applicant SLOR rankings in their summative score. Summative scores were separated into ranked to match, top one-third, middle one-third, lower one-third, and not a fit. Four studies reported the summative SLOR scores of applicants. Our secondary study goal was to assess applicant characteristics associated with SLOR summative scores and assess any bias present in the SLOR or narrative recommendation. Five studies compared SLOR ratings across applicant characteristics including gender, race, USMLE Step 1 score, USMLE Step 2 score, Alpha Omega Alpha (AΩA) membership, clerkship grades, and publications. Gender and racial bias were also assessed across five studies. Four studies utilized a linguistic analysis software to search letters of recommendation for differences in word category use by gender and race. RESULTS: Studies consistently found that a higher percentage of candidates were identified in the top percentile blocks than is mathematically possible. For example, the two studies that tallied the proportion of candidates ranking in the top 10% of applicants found that 36% and 42% were rated as being in the top 10%. Similarly, articles found more than 87% of applicants scored in the top one-third. Studies had mixed results, but in general, they suggested that AΩA status, higher Step 1 scores, and more research publications have a slightly positive association with increased SLOR scores. We found no evidence of gender bias against women, and in fact, most studies evaluating word choices found word choices for women candidates generally were stronger. Similarly, no consistent disparities were identified in word categories utilized in SLORs based on applicant race. CONCLUSION: Most notably, a mathematically impossible proportion of applicants were counted in the top percentiles in letters of recommendation. This compromises readers' abilities to differentiate candidates. Factors like AOA status and research publications displayed a modest positive correlation with SLOR scores. Gender bias against women or candidates from racial minority groups was not evident. CLINICAL RELEVANCE: We suggest that group SLOR authorship, with a consensus assessment by clerkship or residency directors, should be considered. We also recommend the incorporation of mean and SD scores for each letter writer (or group) alongside their letters. Furthermore, studies indicate that submitting all four SLOR letters can substantially improve an applicant's chances of success. We advise students to choose strategically and submit the maximum allowable number of SLORs.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery. METHODS: A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded. RESULTS: There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear. CONCLUSION: This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges.

BACKGROUND: As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. METHODS: This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant. RESULTS: There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82). CONCLUSION: SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review.

BACKGROUND: The pathogenesis of shoulder injury related to vaccine administration (SIRVA) is incompletely understood, but it is postulated to be an immune-mediated inflammatory response to a vaccine antigen, leading to shoulder pain and dysfunction. The purpose of this investigation is to systematically review the literature related to SIRVA specifically after the COVID-19 vaccination by describing the diagnostic and clinical characteristics, diagnoses associated with SIRVA, and incidence between vaccine types. METHODS: A systematic review was performed to identify level I to IV studies and case descriptions of shoulder pain occurring after COVID-19 vaccination. To confirm that no studies were missing from the systematic review, references of studies from the initial search were scanned for additional relevant studies. RESULTS: A total of 22 studies, comprised of 81 patients, were identified meeting the inclusion/exclusion criteria. Reports were most commonly published from countries in Asia (53.1%; n = 43/81). The most commonly described vaccines were Oxford-AstraZeneca at 37.0% (n = 30/81) and Pfizer-BioNTech at 33.3% (n = 27/81). Symptoms occurred most commonly after at least 72 hours of administration (30.9%, n = 25/81). One hundred percent of patients (n = 81/81) described pain as an associated symptom and 90.1% of patients (n = 73/81) described multiple symptoms. The diagnostic modalities utilized to identify a specific pathology consisted of magnetic resonance imaging (55.6%; n = 45/81), ultrasound (28.4; n = 23/81), radiograph (25.9%; n = 21/81), and computed tomography (4.9%; 4/81). Nearly a third of patients (32.1%; n = 26/81) were diagnosed with bursitis, while 22 (27.2%) were diagnosed with adhesive capsulitis, 17 (21.0%) with either rotator cuff tear or tendinopathy, and 14 (17.3%) with polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. The 2 most common treatment options were physical therapy (34.6%; n = 28/81) and nonsteroidal anti-inflammatory medications (33.3%; 27/81). The majority of SIRVA cases (52.1%; n = 38/73) completely resolved within a few weeks to months. CONCLUSION: Despite the limited quality and lack of large-scale studies, it is important for providers to recognize SIRVA as a potential risk factor as the number of patients receiving COVID-19 vaccinations and boosters continues to rise.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Clinical and radiographic outcomes following anatomic total shoulder arthroplasty utilizing an inset glenoid component at 2-year minimum follow-up: a dual center study.

BACKGROUND: Anatomic total shoulder arthroplasty (aTSA) is a successful and reproducible treatment for patients with painful glenohumeral arthritis. However, long-term outcomes using traditional onlay glenoid components have been tempered by glenoid loosening. Inset components have been proposed to minimize glenoid loosening by reducing edge-loading and opposite-edge lift-off forces with humeral translation. Successful short- and long-term outcomes have been reported while using inset glenoid implants. The current study is the largest study presenting a minimum of 2-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI, USA). METHODS: A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by 2 fellowship-trained shoulder surgeons at 2 separate institutions from August, 2016, to August, 2019, was performed. Minimum follow-up was 2 years. Range of motion (ROM), visual analog scale (VAS) pain scores, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores were obtained. Radiographic outcomes, including central peg lucency and glenoid loosening, were assessed by 3 independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up. RESULTS: Seventy-five shoulders were included for the final analysis. The mean age of the entire cohort was 64 (±11.4) years. Twenty-one (28%) glenoids were type A1, 10 (13.3%) were type A2, 13 (17.3%) were type B1, 22 (29.3%) were type B2, 6 (8%) were type B3, and 3 (4%) were type D. At a minimum follow-up of 24 months (mean: 28.7 months), a significant improvement in ROM in all planes was observed. Significant improvements in VAS (5.1-0.9, P < .001), SANE (39.5-91.2, P < .001), and ASES (43.7-86.6, P < .001) scores were observed. There were 4 (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) case of glenoid loosening. No revisions were performed for glenoid loosening. CONCLUSION: At a minimum of 2 years postoperatively, there were significant improvements in ROM, VAS, SANE, and ASES scores with very low rates of central peg lucency and glenoid loosening in patients undergoing aTSA with an inset glenoid component. Further work is needed to determine the long-term benefit of this novel implant.

Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making.

BACKGROUND: There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty. METHODS: Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores. RESULTS: A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were -1.54 ± 2.0, -2.59 ± 2.2, and -2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] -1.03, 95% CI -2.0, -0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4, -0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score. CONCLUSION: Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

Restoration of the native humeral anatomy during stemless anatomic total shoulder arthroplasty: a radiographic comparison of intramedullary versus freehand resection.

BACKGROUND: During anatomic total shoulder arthroplasty (aTSA), the humeral head can be resected with or without the use of an intramedullary cutting guide, the former referred to as intramedullary (IM) resection and the latter referred to as freehand (FH) resection. Outcomes following aTSA are predicated upon the restoration of the native humeral anatomy, which can be more challenging with stemless implants. To date, no studies have determined which method of humeral head resection is superior in restoring native anatomy. Our purpose was to determine whether FH or IM resection was superior in restoring native anatomy during aTSA with stemless implants. METHODS: A review of all patients who underwent aTSA using the stemless Tornier Simpliciti Shoulder System at two academic institutions by two separate surgeons between January 2017 and June 2020 was performed. One surgeon at one institution performed stemless aTSA using the IM resection technique, while the second surgeon utilized the FH resection technique. Patients were excluded if they underwent surgery for an indication other than glenohumeral osteoarthritis, if they received a short-stem or standard-stem implant, or if they lacked adequate preoperative and postoperative Grashey radiographs. One hundred eleven patients across both institutions (51 IM, 60 FH) were included for the final radiographic assessment. The humeral head height (HH) and neck-shaft angle (NSA) were measured on preoperative and postoperative Grashey radiographs. The centers of rotation (CORs) were measured on postoperative Grashey radiographs. Patients were classified as having acceptable restoration of their native anatomy if the change (Δ) in COR or HH was ≤3 mm and ≤ 5 mm, respectively, or if the postoperative NSA was ≥130°. RESULTS: IM resection had the greatest acceptable restoration of COR (90.2% IM versus 70% FH, P = .009), HH (96.1% IM vs. 63.3% FH, P < .001), and NSA (96.1% IM vs. 78.3% FH, P = .006) relative to FH resection. The mean postoperative NSAs for the IM and FH cohorts were 134.4° (±2.1°) and 133.8° (±5.4°), respectively (P = .208). The mean ΔCORs for the IM and FH groups were 1.2 (±1.5) and 2.3 (±1.2) mm, respectively (P < .001). Finally, the mean ΔHHs for the IM and FH cohorts were 1.7 (±1.4) and 4.4 (±2.9) mm, respectively (P < .001). CONCLUSIONS: Restoration of the native humeral anatomy following stemless aTSA occurred at a significantly higher rate when using IM vs. FH resection.

Effects of opioid-limiting legislation on postoperative opioid use in shoulder arthroplasty in an epidemic epicenter.

BACKGROUND: The current opioid epidemic in the United States has become a public health crisis with an estimated 150 daily deaths and nearly 47,000 opioid-related deaths in the United States in 2017 alone. Sensible prescriber practice changes have been a focus of policymakers to decrease the total number of narcotic pain medications in circulation. In the state of Ohio, opioid prescription limits for acute pain were enacted in August 2017. However, given the association of acute opioid exposure with long-term use and lack of assessment of these policies, there is an unmet need to evaluate the effects of similar legislation in Ohio on postoperative opioid dosing after shoulder arthroplasty. This study evaluates the effects of opioid prescription-limiting legislation in Ohio on postoperative opioid dosing in shoulder arthroplasty and assesses risk factors related to long-term opioid use. METHODS: All patients undergoing primary and revision shoulder arthroplasty over a 5-year period performed by a single surgeon were included. The pre-legislation (PRE) and post-legislation (POST) groups were defined as patients undergoing shoulder arthroplasty before August 31, 2017 and on or after August 31, 2017, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively. Patients were designated as opioid tolerant if they had filled an opioid prescription within 30 days of surgery. A binary logistic regression analysis was applied to assess factors related to long-term opioid use. RESULTS: A total of 334 patients were categorized into 2 cohorts: PRE (n = 99) and POST (n = 235). Accounting for legislative effects, we observed significant reductions in cumulative morphine milligram equivalent (MME) dosing in the opioid-naive patients in the 7-day and 30-day postoperative periods (450.0 MMEs in PRE group vs. 210.0 MMEs in POST group, P < .001) and in the opioid-tolerant patients in the 7-day postoperative period (450.0 MMEs in PRE group vs. 250.0 MMEs in POST group, P = .001). Among the opioid-naive patients, the POST group had a significant MME reduction in the 90-day postoperative period relative to the PRE cohort (P < .001). Preoperative opioid tolerance and benzodiazepine tolerance were independent risk factors for increased MME dosing at 90 days postoperatively (P < .001 and P = .02, respectively). CONCLUSION: Opioid prescription-limiting legislation for acute pain in the state of Ohio is associated with a notable reduction in opioid MME dosing in the 90-day postoperative period after shoulder arthroplasty, particularly in opioid-naive patients in the first 30 days postoperatively. Preoperative opioid tolerance is correlated with significantly higher MME dosing postoperatively after shoulder arthroplasty.

Early clinical and radiographic outcomes of anatomic total shoulder arthroplasty with a biconvex posterior augmented glenoid for patients with posterior glenoid erosion: minimum 2-year follow-up.

BACKGROUND: Glenoid bone loss in anatomic total shoulder arthroplasty (aTSA) remains a controversial and challenging clinical problem. Previous studies have shown high rates of glenoid loosening for aTSA in shoulders with retroversion, posterior bone loss, and posterior humeral head subluxation. This study is the first to present minimum 2-year follow-up data of an all-polyethylene, biconvex augmented anatomic glenoid component for correction of glenoid retroversion and posterior humeral head subluxation. METHODS: This study is a multicenter, retrospective review of prospectively collected data on consecutive patients from 7 global clinical sites. All patients underwent aTSA using the biconvex posterior augmented glenoid (PAG). Inclusion criteria were preoperative computed tomographic (CT) scan, minimum 2 years since surgery, preoperative and minimum 2-year postoperative range of motion examination, and patient-reported outcome measures (PROMs). Glenoid classification, glenoid retroversion, and posterior humeral head subluxation were measured from preoperative CT and radiography and postoperative radiography. Statistical comparisons between pre- and postoperative values were performed with a paired t test. RESULTS: Eighty-six of 110 consecutive patients during the study period (78% follow-up) met the inclusion criteria and were included in our analysis. Mean follow-up was 35 ± 10 months, with a mean age of 68 ± 8 years (range 48-85). Range of motion statistically improved in all planes from pre- to postoperation. Mean visual analog scale score improved from 5.2 preoperation to 0.7 postoperation, Single Assessment Numeric Evaluation score from 43.2 to 89.5, Constant score from 41.8 to 76.9, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score from 49.8 to 86.7 (all P < .0001). Mean glenoid retroversion improved from 19.3° to 7.4° (P < .0001). Posterior subluxation improved from 69.1% to 53.5% and posterior decentering improved from 5.8% to -3.0% (P < .0001). There was 1 patient with both a prosthetic joint infection and radiographic glenoid loosening that required revision. Seventy-nine of 86 patients had a Lazarus score of 0 (no radiolucency seen about peg or keel) at final follow-up. CONCLUSIONS: This study shows that at minimum 2-year follow-up, a posterior-augmented all-polyethylene glenoid can correct glenoid retroversion and posterior humeral head subluxation. Clinically, there was significant improvement in both range of motion and PROMs.

Ticagrelor Increases Platelet-Mediated Staphylococcus aureus Killing, Resulting in Clearance of Bacteremia.

Platelets are a critical immune defense against Staphylococcus aureus bloodstream infections. Staphylococcus aureus α-toxin is a virulence factor that decreases platelet viability and accelerates platelet clearance. It has been shown that ticagrelor blocks α-toxin-mediated platelet injury and resulting thrombocytopenia, protecting mice in a lethal S. aureus sepsis model. We now present the use of ticagrelor as adjunctive therapy in a patient with a S. aureus endovascular infection and thrombocytopenia, associated with restoration of platelet count and bacteremia clearance. Ticagrelor enhanced platelet killing of the S. aureus bloodstream isolate from the treated patient in vitro.

Volumetric MicroCT Intensity Histograms of Fatty Infiltration Correlate with the Mechanical Strength of Rotator Cuff Repairs: An Ex Vivo Rabbit Model.

BACKGROUND: Fatty infiltration of the rotator cuff occurs after injury to the tendon and results in a buildup of adipose in the muscle. Fatty infiltration may be a biomarker for predicting future injuries and mechanical properties after tendon repair. As such, quantifying fatty infiltration accurately could be a relevant metric for determining the success of tendon repairs. Currently, fatty infiltration is quantified by an experienced observer using the Goutallier or Fuchs staging system, but because such score-based quantification systems rely on subjective assessments, newer techniques using semiautomated analyses in CT and MRI were developed and have met with varying degrees of success. However, semiautomated analyses of CT and MRI results remain limited in cases where only a few two-dimensional slices of tissue are examined and applied to the three-dimensional (3-D) tissue structure. We propose that it is feasible to assess fatty infiltration within the 3-D volume of muscle and tendon in a semiautomated fashion by selecting anatomic features and examining descriptive metrics of intensity histograms collected from a cylinder placed within the central volume of the muscle and tendon of interest. QUESTIONS/PURPOSES: (1) Do descriptive metrics (mean and SD) of intensity histograms from microCT images correlate with the percentage of fat present in muscle after rotator cuff repair? (2) Do descriptive metrics of intensity histograms correlate with the maximum load during mechanical testing of rotator cuff repairs? METHODS: We developed a custom semiautomated program to generate intensity histograms based on user-selected anatomic features. MicroCT images were obtained from 12 adult female New Zealand White rabbits (age 8 to 12 months, weight 3.7 kg ± 5 kg) that were randomized to surgical repair or sham repair of an induced infraspinatus defect. Intensity histograms were generated from images of the operative and contralateral intact shoulder in these rabbits which were presented to the user in a random order without identifying information to minimize sources of bias. The mean and SD of the intensity histograms were calculated and compared with the total percentage of the volume threshold as fat. Patterns of fat identified were qualitatively compared with histologic samples to confirm that thresholding was detecting fat. We conducted monotonic tensile strength-to-failure tests of the humeral-infraspinatus bone-tendon-muscle complex, and evaluated associations between histogram mean and SDs and maximum load. RESULTS: The total percentage of fat was negatively correlated with the intensity histogram mean (Pearson correlation coefficient -0.92; p < 0.001) and positively with intensity histogram SD (Pearson correlation coefficient 0.88; p < 0.001), suggesting that the increase in fat leads to a reduction and wider variability in volumetric tissue density. The percentage of fat content was also negatively correlated with the maximum load during mechanical testing (Pearson correlation coefficient -78; p = 0.001), indicating that as the percentage of fat in the volume increases, the mechanical strength of the repair decreases. Furthermore, the intensity histogram mean was positively correlated with maximum load (Pearson correlation coefficient 0.77; p = 0.001) and histogram SD was negatively correlated with maximum load (Pearson correlation coefficient -0.72; p = 0.004). These correlations were strengthened by normalizing maximum load to account for animal size (Pearson correlation coefficient 0.86 and -0.9, respectively), indicating that as histogram mean decreases, the maximum load of the repair decreases and as histogram spread increases, the maximum load decreases. CONCLUSION: In this ex vivo rabbit model, a semiautomated approach to quantifying fat on microCT images was a noninvasive way of quantifying fatty infiltration associated with the strength of tendon healing. CLINICAL RELEVANCE: Histogram-derived variables may be useful as surrogate measures of repair strength after rotator cuff repair. The preclinical results presented here provide a foundation for future studies to translate this technique to patient studies and additional imaging modalities. This semiautomated method provides an accessible approach to quantification of fatty infiltration by users of varying experience and can be easily adapted to any intensity-based imaging approach. To translate this approach to clinical practice, this technique should be calibrated for MRI or conventional CT imaging and applied to patient scans. Further investigations are needed to assess the correlation of volumetric intensity histogram descriptive metrics to clinical mechanical outcomes.

Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines.

BACKGROUND: Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. METHODS: In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal. RESULTS: A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. DISCUSSION: To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

Evaluating the role of graft integrity on outcomes: clinical and imaging results following superior capsular reconstruction.

BACKGROUND: Superior capsular reconstruction (SCR) addresses massive, irreparable rotator cuff tears in young patients. The purpose of this study was to retrospectively evaluate clinical outcomes and graft integrity in patients following SCR. METHODS: Thirty-four consecutive patients undergoing SCR by 2 surgeons with minimum 2-year follow-up were identified. Functional outcomes were obtained, including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and Single Assessment Numeric Evaluation (SANE) scores. Graft integrity was evaluated on magnetic resonance images (MRIs). RESULTS: Thirty-five shoulders in 34 patients were identified. Four patients underwent subsequent surgery. The mean preoperative scores were SST 21.6 ± 17.6, ASES 28.3 ± 10.1, SANE 50.6 ± 22.1, and VAS 6.6 ± 1.7. The mean postoperative outcomes were SST 79.1 ± 19.6, ASES 79.9 ± 17.4, SANE 74.3 ± 18.7, and VAS 1.5 ± 2.2. There was statistically significant improvement in SST, ASES, and VAS following SCR. MRI revealed graft failure in 62% (n = 13 of 21) of shoulders. Radiographic evidence of graft healing did not have any effect on SST, ASES, SANE, or VAS scores. CONCLUSION: Given the high rate of graft failure without a significant difference in clinical outcomes, graft healing after SCR might not be an independent predictor of success. The improved clinical improvement in patients undergoing SCR may be due to other known beneficial aspects of the procedure, including partial rotator cuff repair, débridement, and biceps management.

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group.

BACKGROUND: Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. METHODS: Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. RESULTS: Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). DISCUSSION: Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Maternal glucocorticoids promote offspring growth without inducing oxidative stress or shortening telomeres in wild red squirrels.

Elevations in glucocorticoid (GC) levels in breeding females may induce adaptive shifts in offspring life histories. Offspring produced by mothers with elevated GCs may be better prepared to face harsh environments, where a faster pace of life is beneficial. We examined how experimentally elevated GCs in pregnant or lactating North American red squirrels (Tamiasciurus hudsonicus) affected offspring postnatal growth, structural size and oxidative stress levels (two antioxidants and oxidative protein damage) in three different tissues (blood, heart and liver) and liver telomere lengths. We predicted that offspring from mothers treated with GCs would grow faster but would also have higher levels of oxidative stress and shorter telomeres, which may predict reduced longevity. Offspring from mothers treated with GCs during pregnancy were 8.3% lighter around birth but grew (in body mass) 17.0% faster than those from controls, whereas offspring from mothers treated with GCs during lactation grew 34.8% slower than those from controls and did not differ in body mass around birth. Treating mothers with GCs during pregnancy or lactation did not alter the oxidative stress levels or telomere lengths of their offspring. Fast-growing offspring from any of the treatment groups did not have higher oxidative stress levels or shorter telomere lengths, indicating that offspring that grew faster early in life did not exhibit oxidative costs after this period of growth. Our results indicate that elevations in maternal GCs may induce plasticity in offspring growth without long-term oxidative costs to the offspring that might result in a shortened lifespan.

Injury frequency and severity in crayfish communities as indicators of physical habitat quality and water quality within agricultural headwater streams.

Crayfishes (Decapoda) are common inhabitants of agricultural headwater streams in the Midwestern USA that have been impacted by physical habitat degradation and contamination by agricultural pollutants. The frequency and severity of injuries within crayfish communities are indicators of crayfish aggression, which is influenced by physical, chemical, and biotic factors. Previous studies have not evaluated the relationships of the frequency and severity of crayfish injuries with physical habitat quality, water quality, and biotic factors within agricultural headwater streams. Understanding these relationships will assist with determining if crayfish injury variables can serve as an indicator of physical habitat quality or water quality in these small degraded streams. We sampled crayfishes, documented the frequency and type of injuries, and measured instream habitat and water chemistry in 2014 and 2015 within 12 agricultural headwater streams in Indiana, Michigan, and Ohio. We documented five native crayfish species from 1641 adult captures. The most abundant species were Faxonius rusticus, Faxonius immunis, and Faxonius propinquus. Linear mixed effect model analyses indicated that four crayfish injury response variables were positively correlated (p < 0.05) with crayfish density, physical habitat quality, and water velocity diversity and that crayfish injury response variables were more strongly correlated with crayfish density than physical habitat quality or water quality. Our results indicate that response variables describing the severity and frequency of crayfish injuries can be effective indicators of physical habitat quality in agricultural headwater streams.

Proliferative glomerulonephritis with monoclonal IgG deposits in children and young adults.

BACKGROUND: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) has been recognized as a distinct entity in recent years. To the best of our knowledge, all patients with PGNMID reported thus far were older than 20 years of age. We now report five cases of PGNMID in patients under 20 years of age. METHODS: The clinical database was searched for patients with native kidney biopsies from 9/2011 to 8/2017, and cases with a diagnosis of PGNMID were retrieved. Light microscopy specimens and immunofluorescence and electron microscopy images were revisited. Clinical data and kidney biopsy findings for patients under the age of 20 were recorded. RESULTS: Five (0.78%) of a total of 637 patients younger than 20 with native renal biopsies had a diagnosis of PGNMID, including three males and two females with an average age of 14 years old (range 10-19). All five patients presented with microscopic hematuria and proteinuria. Three patients were nephrotic and their C3 levels were low. All five cases showed a membranoproliferative pattern with abundant mesangial and subendothelial monoclonal IgG3 deposits (3 κ and 2 λ light chain, respectively). The patients were followed up to 56 months. Two patients had re-biopsies 28 and 18 months after initial diagnosis and both showed similar morphologic changes. Various treatments were attempted including prednisone, mycophenolate mofetil, tacrolimus, rituximab, and eculizmab, with mixed responses. CONCLUSIONS: PGNMID does occur in children and young adults. Membranoproliferative glomerulonephritis pattern with monoclonal IgG3 deposits is a common feature. Despite various immunosuppressive treatments, the disease appears slowly progressive.

Hereditary Lysozyme Amyloidosis Variant p.Leu102Ser Associates with Unique Phenotype.

Lysozyme amyloidosis (ALys) is a rare form of hereditary amyloidosis that typically manifests with renal impairment, gastrointestinal (GI) symptoms, and sicca syndrome, whereas cardiac involvement is exceedingly rare and neuropathy has not been reported. Here, we describe a 40-year-old man with renal impairment, cardiac and GI symptoms, and peripheral neuropathy. Renal biopsy specimen analysis revealed amyloidosis with extensive involvement of glomeruli, vessels, and medulla. Amyloid was also detected in the GI tract. Echocardiographic and electrocardiographic findings were consistent with cardiac involvement. Proteomic analysis of Congo red-positive renal and GI amyloid deposits detected abundant lysozyme C protein. DNA sequencing of the lysozyme gene in the patient and his mother detected a heterozygous c.305T>C alteration in exon 3, which causes a leucine to serine substitution at codon 102 (Human Genome Variation Society nomenclature: p.Leu102Ser; legacy designation: L84S). We also detected the mutant peptide in the proband's renal and GI amyloid deposits. PolyPhen analysis predicted that the mutation damages the encoded protein. Molecular dynamics simulations suggested that the pathogenesis of ALys p.Leu102Ser is mediated by shifting the position of the central ß-hairpin coordinated with an antiparallel motion of the C-terminal helix, which may alter the native-state structural ensemble of the molecule, leading to aggregation-prone intermediates.