Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness. METHODS: The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period. RESULTS: A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively. CONCLUSIONS: The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Anatomic TSA for B2 glenoids treated with asymmetric reaming has equivalent survivorship and patient outcomes compared to type A glenoids at mean 9 years follow-up.

BACKGROUND: Walch B2 glenoids can present a challenge to shoulder arthroplasty surgeons. Short-term studies have demonstrated that corrective reaming to 10° of retroversion in anatomic total shoulder arthroplasty (aTSA) can result in good outcomes, however there is little data reporting the long-term outcomes in this cohort. B2 glenoids treated with high-side reaming present a theoretical risk of early glenoid component failure as one may ream into the subchondral bone. This study aimed to demonstrate that 1) B2 glenoids treated with corrective reaming have durable results and 2) offer similar results to Walch A1/2 in long-term follow-up. METHODS: Patients who underwent aTSA by a single surgeon (E.L.F.) were identified from a shoulder arthroplasty registry. Inclusion criteria included Walch A1, A2 or B2 glenoid, a diagnosis of primary shoulder osteoarthritis, and a minimum radiographic and clinical follow-up of 5 years. 43 patients with B2 glenoids were compared to a cohort of 42 patients with A1 or A2 glenoids. Preoperative computed tomography (CT) and radiographs were utilized to assess deformity, glenoid version, and posterior subluxation of the humeral head. Postoperatively, patients were assessed with radiographs and patient-reported outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and Visual Analog Scale (VAS). RESULTS: 85 shoulders (82 patients, 42 B2 and 43 A1/A2 glenoids) with an average follow-up of 9.4 years were included. In the B2 cohort, the average retroversion was 21.1° and posterior subluxation was 69.4% compared with 10.6°(p<0.001) and 57.5% (p<0.001) in the A1 or A2 cohort. The cohort demographics were similar except for male sex (B2 69.8% vs A1 or A2 37.2%, p=0.008). There was no difference between the cohorts in their improvement in ASES (p=0.807), SST (p=0.586), or VAS (p=0.930) scores. There was no difference in lateral humeral offset (p=0.889) or acromial humeral interval (p=0.468) between initial postoperative and final follow-up visits. Survivorship for B2 glenoids was 97.6%, 94.1% and 73.3% at 5, 10 and 15 years, respectively compared to 97.6%, 91.9% and 83.5% in type A glenoids. The revision rate was similar between the two groups (p=0.432). Lazarus score (p=0.682) and rates of humeral radiolucency (p=0.366) and humeral osteolysis (p=0.194) were similar between the two cohorts at final follow-up. CONCLUSION: Asymmetric reaming of patients with B2 glenoids is a reliable method of glenoid preparation with excellent mid- to long-term clinical results, patient reported outcomes, and low revision rates similar to their A1 and A2 counterparts.

Cemented vs. press-fit humeral stems: a matched cohort analysis at a mean follow-up of 10 years.

BACKGROUND: Although cementation of humeral stems has long been considered the gold standard for anatomic shoulder arthroplasty (aTSA), cementless, or press-fit, fixation offers a relatively cheaper and less demanding alternative, particularly in the setting of a revision procedure. However, this approach has been accompanied by concerns of implant loosening and high rates of radiolucency. In the present study, we performed a propensity-matched comparison of clinical and patient-reported outcomes between cemented and cementless fixation techniques for aTSA. We hypothesized that cemented fixation of the humeral component would have significantly better implant survival while providing comparable functional outcomes at final follow-up. METHODS: This study was a retrospective comparison of 50 shoulders undergoing aTSA: 25 using cemented humeral fixation vs. 25 using press-fit humeral fixation. Patients in the 2 groups were propensity matched according to age, sex, and preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. Primary outcome measures included range of motion (ROM) (forward elevation, external rotation, internal rotation), patient-reported outcomes (ASES, Simple Shoulder Test [SST], visual analog scale [VAS]), and implant survival. RESULTS: At baseline, the 2 fixation groups were similar in regard to age, sex, body mass index, preoperative ASES score, and surgical indication. Mean follow-up was 11.7 ± 4.95 years in the cemented cohort and 9.13 ± 3.77 years in the press-fit cohort (P = .045). Both groups demonstrated significant improvements postoperatively in all included ROM and patient-reported outcomes. However, press-fit patients reported significantly better VAS, ASES, and SST scores. Mean VAS pain score was 1.1 ± 1.8 in press-fit patients and 3.2 ± 3.0 in cemented patients (P = .005). The mean ASES score was 87.7 ± 12.4 in press-fit patients and 69.5 ± 22.7 in cemented patients (P = .002). Lastly, the mean SST score was 9.8 ± 3.1 in press-fit patients and 7.7 ± 3.7 in cemented patients (P = .040). Both fixation techniques provided lasting implant survivorship with only a single revision operation in each of the cohorts. CONCLUSION: Herein, we provide a propensity-matched, long-term comparison of patients receiving anatomic shoulder arthroplasty stratified according to humeral stem fixation technique. The results of this analysis illustrate that both types of humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up.

The role of body mass index in survivorship and clinical outcomes in total shoulder arthroplasty.

BACKGROUND: Increased body mass index (BMI) is a potential risk factor for poorer outcomes and complications. However, the influence of BMI on the long-term outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) remains to be fully elucidated. METHODS: Institutional records were queried to identify patients who underwent primary total shoulder arthroplasty (TSA) between 2009 and 2020 with a minimum of 2 years of clinical follow-up. Retrospective review was performed to collect demographic characteristics; comorbidity status; and range-of-motion and strength measurements in forward elevation, external rotation, and internal rotation. Patients were contacted by telephone to provide patient-reported outcomes (PROs). Patients were stratified into 3 cohorts by BMI: underweight or normal weight (U/NW, BMI ≤25 kg/m2), overweight (OW, BMI >25 to ≤30 kg/m2), and obese (BMI >30 kg/m2). RESULTS: Among 466 TSA patients, 245 underwent aTSA whereas 221 underwent rTSA. In the aTSA cohort, 40 patients were classified as U/NW; 72, as OW; and 133, as obese. Comparatively, the rTSA cohort was composed of 33 U/NW, 79 OW, and 209 obese patients. Patients in the aTSA and rTSA cohorts had an average follow-up period of 5.8 ± 3.2 years and 4.5 ± 2.3 years, respectively. No differences in age at surgery were found in the aTSA group (U/NW vs. obese, 65.2 ± 7.9 years vs. 61.9 ± 8.9 years; P = .133); however, in the rTSA cohort, BMI was found to be inversely related to age at surgery (U/NW vs. obese, 72.4 ± 8.8 years vs. 65.7 ± 8.3 years; P < .001). Across all BMI cohorts, patients saw great improvements in range of motion and strength. Postoperative PROs after TSA did not vary by BMI in terms of Single Assessment Numeric Evaluation, Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons scores. There was no significant difference in survival rates at 10-year follow-up in the aTSA cohort (U/NW vs. obese, 95.8% vs. 93.2%; P = .753) or rTSA cohort (U/NW vs. obese, 94.7% vs. 94.5%; P = .791). CONCLUSION: With dramatic improvements in range of motion, minimal differences in PROs, and high rates of implant survival, TSA is a safe and effective treatment option for all patients, including overweight and obese patients.

Mid-term outcomes following reverse total shoulder arthroplasty.

PURPOSE: The utilization of reverse total shoulder arthroplasty now exceeds the incidence of anatomic shoulder arthroplasty. Previous mid-to-long-term studies on rTSA have reported a decrease in shoulder function as follow-up increased. The purpose of this study was to provide data on mid-term outcomes and implant survival in a series focusing on reverse total shoulder arthroplasty. MATERIALS AND METHODS: Demographic information such as age at surgery, revision surgery status, BMI, and smoking status were recorded. The clinical endpoints measured in this study were range of motion scores (forward elevation, external rotation, internal rotation) and patient reported outcomes (VAS, ASES, SST). Radiographic variables captured included preoperative glenoid morphology, humeral lucency, and glenoid loosening. RESULTS: Fifty-six shoulders were included in this study. The overall mean age at surgery was 72.5 ± 7.2 years with an average follow-up time of 6.8 ± 3.5 years. The mean BMI was 28.1 ± 5.5. All measurements of range of motion saw significant and sustained improvements. Overall, forward elevation improved from 82° preoperatively to 133° postoperatively (p < 0.01). External rotation improved from 23° preoperatively to 36° (p < 0.01), while internal rotation improved from L3 to L1 (p = 0.05). ASES scores improved from 31 preoperatively to 70 postoperatively (p < 0.01). SST scores improved from 2 preoperatively to 7 (p < 0.01). VAS pain index scores improved from 6 to 2 following surgery (p < 0.01). Postoperative scapular notching was seen in 18 patients at final follow-up. Glenoid loosening was seen in 3 shoulders. Humeral loosening was seen in 18 shoulders. Tuberosity resorption was seen in 8 shoulders. The 5 year survival estimate was 98%, and the 10 year survival estimate was 83%. CONCLUSION: In this series, we found that rTSA provides mid-term improvements in range of motion in patients while reducing pain levels. When considered together, this demonstrates that most patients undergoing rTSA can have excellent use of their shoulder from age at surgery to end-of-life.

Does body mass index influence long-term outcomes after anatomic total shoulder arthroplasty?

BACKGROUND: As of 2018, upwards of 42% of the US adult population was considered obese based on body mass index (BMI) scales. With the annual number of total joint replacements increasing, this study aimed to evaluate the impact BMI has on anatomic total shoulder arthroplasty (aTSA) outcomes. METHODS: This was a retrospective analysis of 128 shoulders requiring primary aTSA. Patients were stratified into 3 cohorts based on their BMI at surgery: underweight/normal weight (U/NW; BMI ≤25.0), overweight (25.0 < BMI ≤ 30.0), and obese (BMI >30.0). BMI was separately analyzed as a continuous variable. Clinical endpoints were range of motion scores, including forward elevation, external rotation, and internal rotation, and patient-reported outcomes, including visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, and the Simple Shoulder Test (SST). Survivorship curves were calculated using Kaplan-Meier analysis. RESULTS: Forty-four, 50, and 34 patient shoulders were in the U/NW, overweight, and obese cohorts, respectively. The mean follow-up time was 11.4 years. The U/NW cohort had more females (73%) compared with the overweight (34%; P = .0030) and obese (35%; P = .0015) groups; no differences were seen in revision rates. BMI was negatively correlated with age at surgery (r = -0.19, P = .014); it was not correlated with any of the 6 postoperative clinical endpoints. All 3 cohorts saw significant improvements in forward elevation, external rotation, internal rotation and VAS, ASES, and SST scores when compared preoperatively to postoperatively (P < .001). There were no significant differences between the 3 cohorts with respect to postoperative range of motion. Postoperative ASES scores were higher for the overweight cohort (82.6 ± 18.6) compared with both the U/NW (63.0 ± 25.1) and obese cohorts (70.5 ± 26.8) (P < .001). The overweight cohort also had higher SST (P = .0012) postoperative scores compared with the U/NW and obese cohorts; VAS scores were comparable between groups (P = .12). The nonobese (BMI <30) group (n = 94) showed 5-, 10-, and 15-year implant survival of 98.9%, 94.9%, and 83.9%, respectively compared to 97.1%, 93.7%, and 87.0% in the obese (BMI ≥30) group (n = 34). The log rank test revealed no significant difference in survival curves (P = .82). CONCLUSION: To our knowledge, this is the longest follow-up study analyzing clinical endpoints stratified by BMI for aTSA. We saw that patients with a higher BMI required shoulder replacement at a significantly younger age. However, we also report that regardless of BMI, all patients saw significant improvements in patient-reported outcomes and range of motion scores postoperatively.

Superior migration of the humeral head does not significantly affect outcomes at an average of 11 years after total shoulder arthroplasty.

BACKGROUND: Superior migration of the humeral head has been linked with rotator cuff dysfunction and glenoid loosening after total shoulder arthroplasty (TSA). We aimed to determine if superior migration was associated with poor shoulder function following anatomic TSA at long-term follow-up. METHODS: In this retrospective cohort study, we reviewed patients undergoing TSA by a single surgeon at an urban, academic institution. To study the effect of superior migration on TSA outcomes, we stratified the cohort by ≥ and <7 mm of acromiohumeral interval (AHI) and compared range of motion and patient reported outcomes (PROs). Clinical variables included preoperative and postoperative forward elevation (FE), internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, and Simple Shoulder Text score. Radiographic variables included immediate postoperative and long-term follow-up AHI, lateral humeral offset, and glenoid loosening scores. RESULTS: After applying exclusion criteria, 121 TSAs were included. The mean age was 63.9 ± 9.5 years, and 66 surgeries (55%) were in male patients. The mean follow-up for our cohort was 11.2 years (range, 5-26 years). Nine shoulders underwent revision surgery. All range of motion and PROs improved significantly from preoperative to the most recent postoperative follow-up. The mean AHI immediately following surgery was 10.9 ± 4.1 mm, while the mean AHI at most recent follow-up was 8.4 ± 3.5 mm. Glenoid loosening was observed in 29 (23.8%) shoulders at the most recent follow-up appointment. Although AHI correlated weakly with FE (r = 0.252; P = .006), we did not observe a clear threshold of migration which led to degraded function. Importantly, glenoid loosening was not related to AHI at long-term follow-up (P = .631). None of FE, internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, Simple Shoulder Text, or revisions were significantly different between patients with ≥ and <7 mm of AHI. CONCLUSION: Our results suggest that anatomic TSA provides durable improvements to pain, function, and PROs despite changes to the AHI.

Outcomes of Reverse Total Shoulder Arthroplasty Were Not Adversely Affected by the COVID-19 Pandemic.

Introduction: The objective was to investigate outcomes in reverse total shoulder arthroplasty (RTSA) in patients affected by the COVID-19 pandemic shutdown. We hypothesized that patients undergoing RTSA in early 2020 would have decreased access to physical therapy (PT) and worse postoperative outcomes compared to historical controls. Materials and Methods: Patients who received primary RTSA between 1/1/2020 to 3/17/2020 were included and patients who received primary RTSA between 1/1/2019 to 3/17/2019 were used as a control group. Retrospective chart review was performed, and patient reported outcomes were recorded at an average of 2.69 ± 0.06 years and a minimum of 1 year postoperatively. Patient data were collected and statistically analyzed using the 2-sample t-test and Chi-square test. The Mann Whitney U test and Fisher's Exact test were used when appropriate. Results: 38 patients in 2020 were included in this study and compared to 31 patients in 2019. RTSA performed in 2019 had improvements in forward elevation (FE) (95.7º ± 47.2º to 144.7º ± 17.2º, p<0.001), but not in external rotation (ER) (32.5º ± 20.3º to 41.0º ± 13.3º, p=0.15), or internal rotation (IR) (S1 to L5, p=0.76). RTSA 2020 cases had improvements in FE (111.5º ± 40.3 to 132.8º ± 30.6, p=0.016), but not ER (31.9º ± 18.2 to 35.7º ± 15.9, p=0.36) or IR (S1 to L5, p=0.13). Patients in 2019 (FE: 4 to 5-, p<0.001; ER: 4+ to 5-, p=0.003; IR: 5- to 5, p<0.001) and 2020 (FE: 4 to 5-, p<0.001; ER: 4+ to 5, p<0.001; IR: 5- to 5, p=0.02) both experienced improvements in strength. Patients in 2020 initiated PT later (2019: 39.3 ± 27.3 days, 2020: 57.1 ± 35.5 days, p=0.028) and completed less PT sessions (2019: 20.7 ± 11.1, 2020: 12.9 ± 6.6, p<0.001) than patients in 2019. In the 2020 cohort, 10.5% (4/38) did not complete any PT, 34.2% (13/38) reported a delay in initiating PT, and 47.4% (18/38) reported that their recovery was negatively affected by the COVID-19 pandemic. At final follow-up, patients in 2020 reported a mean SANE score of 73.6 ± 17.5 on their affected shoulder and a mean VAS score of 1.68 ± 1.23. Discussion: Despite a delay in initiating PT and completing less PT overall, patients who received RTSA in 2020 experienced significant improvements in ROM and strength at final follow-up and were comparable to the 2019 patients.

Addition of the Sartorius Tendon Improves Biomechanics of a Four-Strand Hamstring Anterior Cruciate Ligament Autograft.

PURPOSE: The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties. METHODS: Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A P < .05 was considered statistically significant. RESULTS: The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft. CONCLUSIONS: The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation. CLINICAL RELEVANCE: The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

Long-term clinical and radiographic outcomes of total shoulder arthroplasty in patients under age 60 years.

BACKGROUND: We aimed to characterize the long-term clinical and radiographic outcomes of total shoulder arthroplasty (TSA) in patients aged < 60 years. We hypothesized meaningful improvements in shoulder functionality and pain with TSA and an acceptably low rate of prosthesis complications and revisions. METHODS: This was a retrospective cohort study of 29 patients (34 shoulders) undergoing TSA before age 60 years with a minimum follow-up period of 10 years. Shoulder range of motion, functionality (American Shoulder and Elbow Surgeons and Simple Shoulder Test scores), and pain (visual analog scale score) were evaluated. Radiographs were assessed for lateral humeral offset, the acromiohumeral interval, and glenoid loosening. RESULTS: The mean age of the patients was 54.4 ± 5.5 years (range, 35.5-59.8 years), with a mean follow-up period of 16.1 ± 4.5 years (range, 10.0-26.1 years). In patients aged < 60 years, TSA significantly improved forward elevation (from 119° ± 26° to 146° ± 21°, P = .0002), external rotation (from 21° ± 25° to 52° ± 15°, P = .0001), and internal rotation (from L5 to L1, P = .002). Additionally, TSA significantly increased American Shoulder and Elbow Surgeons scores (from 32 ± 20 to 64 ± 27, P = .0008) and Simple Shoulder Test scores (from 3 ± 2 to 7 ± 4, P = .0004) and reduced visual analog scale pain scores (from 7 ± 3 to 3 ± 3, P = .0001). Radiographically, there was no significant difference in mean lateral humeral offset (13 ± 6 mm vs. 10 ± 12 mm, P = .472) or the mean acromiohumeral interval (20 ± 4.2 mm vs. 16 ± 6 mm, P = .061) between immediate postoperative and final follow-up radiographs. Radiographic evidence of glenoid loosening was noted in 2 patients. Complications occurred in 6 patients (17.6%), all of which were cases of aseptic glenoid loosening. Ultimately, 4 patients underwent conversion to a reverse TSA and 2 underwent arthroscopic glenoid removal. The rate of prosthesis survivorship was 97.1% (95% confidence interval [CI], 91.4%-100%) at 10 years, 85.4% (95% CI, 73.7%-97.2%) at 15 years, and 80.1% (95% CI, 65.1%-98.4%) at 20 years. DISCUSSION: TSA consistently improved shoulder functionality and reduced pain while limiting the need for further revisions. These findings suggest that TSA is a viable treatment option for glenohumeral arthritis in younger patients.

Survivorship of total shoulder arthroplasty vs. hemiarthroplasty for the treatment of avascular necrosis at greater than 10-year follow-up.

BACKGROUND: Avascular necrosis (AVN) of the humeral head is a debilitating pathology that can be managed with an array of treatments depending on disease staging. Humeral head arthroplasty for AVN has demonstrated good short-term improvements in pain and range of motion, but the published long-term outcomes data are limited. The objective of this study was to report long-term survivorship and outcomes for patients undergoing hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for the treatment of AVN of the humeral head. METHODS: The practice of one fellowship-trained shoulder surgeon was queried for the surgical treatment of AVN of the humeral head via appropriate International Classification of Diseases, Ninth and Tenth Revision, codes. Sixteen shoulders that met inclusion criteria were identified. Demographics included the radiographic stage, age, sex, American Society of Anesthesiologists (ASA) score, and body mass index. The primary endpoint was survivorship of the implant. Secondary endpoints were range of motion in forward elevation, internal and external rotation, visual analog scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Simple Shoulder Test score. RESULTS: Of the 16 shoulders included in the study, 10 underwent HA and 6 underwent TSA. The TSA cohort was significantly older (mean 60.5 vs. 44.2, P = .005), with a higher mean ASA score (mean 3.0 vs. 2.13, P = .02) than the HA group. The 10-year survivorship rates were 88.9% for HA and 80% for TSA with no significant difference between groups. Survivorship data were available for a mean 13.0 ± 5.6 years' follow-up in the HA group and 13.8 ± 4.8 years in the TSA group. When compared to one another, the results between HA and TSA only differed in internal rotation, which was statistically significantly improved in the TSA group compared with HA (2.3 ± 2.6 compared with -3.0 ± 5.0, P = .03). CONCLUSION: The survivorship of both TSA and HA for the treatment of AVN was at least 80% at 10 years. Secondary endpoints, such as range of motion, pain, and shoulder function, improved significantly postoperatively in each cohort and were similar between the 2 groups, except for internal rotation, which had improved significantly more in the TSA group than in HA. Both TSA and HA are viable options for the treatment of AVN, each with durable long-term survival.

Molecular nature and physiological role of the mitochondrial calcium uniporter channel.

Calcium (Ca2+) signaling is critical for cell function and cell survival. Mitochondria play a major role in regulating the intracellular Ca2+ concentration ([Ca2+]i). Mitochondrial Ca2+ uptake is an important determinant of cell fate and governs respiration, mitophagy/autophagy, and the mitochondrial pathway of apoptosis. Mitochondrial Ca2+ uptake occurs via the mitochondrial Ca2+ uniporter (MCU) complex. This review summarizes the present knowledge on the function of MCU complex, regulation of MCU channel, and the role of MCU in Ca2+ homeostasis and human disease pathogenesis. The channel core consists of four MCU subunits and essential MCU regulators (EMRE). Regulatory proteins that interact with them include mitochondrial Ca2+ uptake 1/2 (MICU1/2), MCU dominant-negative ß-subunit (MCUb), MCU regulator 1 (MCUR1), and solute carrier 25A23 (SLC25A23). In addition to these proteins, cardiolipin, a mitochondrial membrane-specific phospholipid, has been shown to interact with the channel core. The dynamic interplay between the core and regulatory proteins modulates MCU channel activity after sensing local changes in [Ca2+]i, reactive oxygen species, and other environmental factors. Here, we highlight the structural details of the human MCU heteromeric assemblies and their known roles in regulating mitochondrial Ca2+ homeostasis. MCU dysfunction has been shown to alter mitochondrial Ca2+ dynamics, in turn eliciting cell apoptosis. Changes in mitochondrial Ca2+ uptake have been implicated in pathological conditions affecting multiple organs, including the heart, skeletal muscle, and brain. However, our structural and functional knowledge of this vital protein complex remains incomplete, and understanding the precise role for MCU-mediated mitochondrial Ca2+ signaling in disease requires further research efforts.

Medication safety in a pandemic: A multicentre point prevalence study of QTc monitoring of hydroxychloroquine for COVID-19.

WHAT IS KNOWN AND OBJECTIVE: A pandemic can strain all aspects of the healthcare system, including the ability to monitor the safety of medication use. Reviewing the adequacy of medication safety practices during the COVID-19 pandemic is critical to informing responses to future pandemics. The purpose of this study was to evaluate medication safety practices at a height of both COVID-19 cases and hydroxychloroquine use. METHODS: This was a multicentre observational point prevalence study. Adult inpatients receiving hydroxychloroquine for COVID-19 between March 22 and 28, 2020 were included. The primary outcome was the percentage of patients receiving appropriate QTc monitoring. Secondary outcomes included QTc prolongation, early discontinuation of hydroxychloroquine and ventricular arrhythmias. RESULTS AND DISCUSSION: A total of 59% (167/284) of patients treated with hydroxychloroquine received appropriate QTc monitoring. QTc prolongation occurred in 25%. Hydroxychloroquine was prematurely discontinued in 1.4% of patients, all due to QTc prolongation. Ventricular arrhythmia occurred in 1.1%. WHAT IS NEW AND CONCLUSION: Medication safety practices were suboptimal with regard to hydroxychloroquine monitoring at the height of the COVID-19 pandemic. Preparation for future pandemics should devote considerable attention to medication safety.

Surgeon Decision-Making for Individuals With Obesity When Indicating Total Joint Arthroplasty.

BACKGROUND: Obesity is a risk factor for complications after total joint arthroplasty (TJA). This study analyzed the impact of individual surgeon demographics, financial concerns, and other factors in determining patient candidacy for TJA based on body mass index (BMI). METHODS: A 21-question survey was approved by the American Association of Hip and Knee Surgeons Research Committee for distribution to its membership. Objective questions asked about surgeon or hospital BMI thresholds for offering TJA. Subjective questions asked about physician comfort discussing topics including obesity, bariatric surgery, and weight loss before TJA, as well as insurance and age considerations. RESULTS: For TJA procedures, 49.9% of surgeons had a BMI cutoff at 40, 24.5% at 45, and 8.3% at 50. At a BMI cutoff of 40, 23.8% of surgeons felt their patient volume would be adversely affected, whereas at a BMI cutoff of 35, 50% of surgeons felt their patient volume would be adversely affected. Surgeons were more likely to not perform total hip arthroplasty on patients with morbid obesity than total knee arthroplasty (P = .037). Significantly more academic surgeons did not have cutoffs for total hip arthroplasty (P = .003) or total knee arthroplasty (P < .001) compared with all other practice settings. CONCLUSION: There are myriad factors that affect surgeon BMI thresholds for offering elective TJA including poor outcomes, hospital thresholds, financial considerations, and the well being of the patient. Further work should be performed to minimize the risks associated with TJA while providing the best possible care to patients with morbid obesity.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk.

BACKGROUND: Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without. METHODS: Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant. RESULTS: Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9). CONCLUSION: Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Monocyte recruitment and fate specification after myocardial infarction.

Monocytes are critical mediators of the inflammatory response following myocardial infarction (MI) and ischemia-reperfusion injury. They are involved in both initiation and resolution of inflammation and play an integral role in cardiac repair. The antagonistic nature of their function is dependent on their subset heterogeneity and biphasic response following injury. New advancements in single-cell transcriptomics and mass cytometry have allowed us to identify smaller, transcriptionally distinct clusters that may have functional relevance in disease and homeostasis. Additionally, recent insights into the spatiotemporal dynamics of monocytes following ischemic injury and their subsequent interactions with the endothelium and other immune cells reveal a complex interplay between monocytes and the cardiac milieu. In this review, we highlight recent findings on monocyte functional heterogeneity, present new mechanistic insight into monocyte recruitment and fate specification following MI, and discuss promising therapeutic avenues targeting monocytes for the treatment of ischemic heart disease.

Outcomes of convergent atrial fibrillation ablation with continuous rhythm monitoring.

BACKGROUND: Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation. METHODS: We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM. RESULTS: Across the entire cohort, 88% had either persistent or long-standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow-up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow-up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post-CP and 64% were off AADs at the last follow-up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub-xiphoid surgical access: 23% versus 3.8% (P = .005) CONCLUSIONS: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub-xiphoid surgical access. Future trials will be necessary to determine which patients are most likely to benefit from the convergent approach.

Experiences of managerial accountability in Ethiopia's primary healthcare system: a qualitative study.

BACKGROUND: Despite calls for improved accountability in global health systems, and a set of clear and consistent theoretical accountability frameworks, empirical descriptions of how accountability is experienced and enacted in low- and middle- income country (LMIC) settings is limited. Therefore, we sought to characterize how managers at all levels of Ethiopia's primary healthcare system experience accountability in their daily practice. METHODS: We conducted in-depth key informant interviews with 41 key stakeholders across 4 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples, and Tigray) in the context of the Primary Healthcare Transformation Initiative (PTI). Consistent with the principles of grounded theory, our team used the constant comparative method to identify emergent themes related to concrete areas that could be targeted to allow an overall culture of accountability to flourish. RESULTS: Emergent themes were: development of a shared understanding of system-wide accountability, streamlining of managerial reporting lines, strengthening of medico-legal knowledge and systems, and development of mechanisms for bottom-up accountability. CONCLUSIONS: Findings may be valuable to policymakers seeking to create more effective national accountability frameworks; practitioners and development partners seeking to strengthen implementation of evidence-based accountability systems and practices; and researchers aiming to develop meaningful, practical measures of accountability in public health.

Outcomes of Micra leadless pacemaker implantation with uninterrupted anticoagulation.

BACKGROUND: Implantation of the MICRA Leadless pacemaker requires the use of a 27 French introducer, blunt delivery system and device fixation to the myocardium via nitinol tines. While prior studies have proven its safety, it is unclear whether performing this procedure with uninterrupted anticoagulation exposes patients to increased risks. We sought to investigate the feasibility and safety of continuing therapeutic anticoagulation during the periprocedural period. METHODS: We evaluated all patients undergoing MICRA placement at our institution between April 2014 and August 2018 with complete follow-up data (n = 170). Patients were stratified into two groups: those on active anticoagulation (OAC, n = 26), defined as having an International normalized ratio >2.0 or having continued a direct oral anticoagulant, and those not anticoagulated (Off-OAC, n = 144). We evaluated for a composite outcome of all major complications, including access site complications and pericardial effusion. RESULTS: OAC and Off-OAC groups had similar mean age (74 ± 13 vs 75 ± 13 years; P = .914). The OAC group had a nonsignificantly lower prevalence of end-stage renal disease (8% vs 17%; P = .375) and aspirin use (27% vs 47%; P = .131). Those in the OAC group were more likely to be on warfarin than those in the Off-OAC group (81% vs 30%; P < .001). The rate of the composite endpoint was similar between the OAC and Off-OAC groups (3.8 % vs 1.4%, respectively; P = .761). Length of stay was similar between groups (1.3 ± 2.6 vs 2.3 ± 3.4 days; P = 0.108). CONCLUSION: Continuation of therapeutic anticoagulation during MICRA implantation appears to be feasible, safe and associated with shorter hospitalization among appropriately selected individuals.

Loss of plasmacytoid dendritic cell differentiation is highly predictive for post-induction measurable residual disease and inferior outcomes in acute myeloid leukemia.

Measurable residual disease is associated with inferior outcomes in patients with acute myeloid leukemia (AML). Measurable residual disease monitoring enhances risk stratification and may guide therapeutic intervention. The European LeukemiaNet working party recently came to a consensus recommendation incorporating leukemia associated immunophenotype-based different from normal approach by multi-color flow cytometry for measurable residual disease evaluation. However, the analytical approach is highly expertise-dependent and difficult to standardize. Here we demonstrate that loss of plasmacytoid dendritic cell differentiation after 7+3 induction in AML is highly specific for measurable residual disease positivity (specificity 97.4%) in a uniformly treated patient cohort. Moreover, loss of plasmacytoid dendritic cell differentiation as determined by a blast-to-plasmacytoid dendritic cell ratio >10 was strongly associated with inferior overall and relapse-free survival (RFS) [Hazard ratio 2.79, 95% confidence interval (95%CI): 0.98-7.97; P=0.077) and 3.83 (95%CI: 1.51-9.74; P=0.007), respectively), which is similar in magnitude to measurable residual disease positivity. Importantly, measurable residual disease positive patients who reconstituted plasmacytoid dendritic cell differentiation (blast/ plasmacytoid dendritic cell ratio <10) showed a higher rate of measurable residual disease clearance at later pre-transplant time points compared to patients with loss of plasmacytoid dendritic cell differentiation (blast/ plasmacytoid dendritic cell ratio <10) (6 of 12, 50% vs 2 of 18, 11%; P=0.03). Furthermore pre-transplant plasmacytoid dendritic cell recovery was associated with superior outcome in measurable residual disease positive patients. Our study provides a novel, simple, broadly applicable, and quantitative multi-color flow cytometry approach to risk stratification in AML.