Gender health gap pre- and post-joint arthroplasty: identifying affected patient-reported health domains.

BACKGROUND: As patient-reported outcomes (PROs) gain prominence in hip and knee arthroplasty (HA and KA), studies indicate PRO variations between genders. Research on the specific health domains particularly impacted is lacking. Hence, we aim to quantify the gender health gap in PROs for HA/KA patients, differentiating between general health, health-related quality of life (HrQoL), physical functioning, pain, fatigue, and depression. METHODS: The study included 3,693 HA patients (1,627 men, 2,066 women) and 3,110 KA patients (1,430 men, 1,680 women) receiving surgery between 2020 to 2021 in nine German hospitals, followed up until March 2022. Questionnaires used were: EQ-VAS, EQ-5D-5L, HOOS-PS, KOOS-PS, PROMIS-F-SF, PROMIS-D-SF, and a joint-specific numeric pain scale. PROs at admission, discharge, 12-months post-surgery, and the change from admission to 12-months (PRO-improvement) were compared by gender, tested for differences, and assessed using multivariate linear regressions. To enable comparability, PROs were transformed into z-scores (standard deviations from the mean). RESULTS: Observed differences between genders were small in all health domains and differences reduced over time. Men reported significantly better health versus women pre-HA (KA), with a difference of 0.252 (0.224) standard deviations from the mean for pain, 0.353 (0.243) for fatigue (PROMIS-F-SF), 0.327 (0.310) for depression (PROMIS-D-SF), 0.336 (0.273) for functionality (H/KOOS-PS), 0.177 (0.186) for general health (EQ-VAS) and 0.266 (0.196) for HrQoL (EQ-5D-5L). At discharge, the gender health gap reduced and even disappeared for some health dimensions since women improved in health to a greater extent than men. No gender health gap was observed in most PRO-improvements and at month 12. CONCLUSIONS: Men experiencing slightly better health than women in all health dimensions before surgery while experiencing similar health benefits 12-months post-surgery, might be an indicator of men receiving surgery inappropriately early, women unnecessarily late or both. As studies often investigate the PRO-improvement, they miss pre-surgery gender differences, which could be an important target for improvement initiatives in patient-centric care. Moreover, future research on cutoffs for meaningful between-group PRO differences per measurement time would aid the interpretation of gender health disparities. TRIAL REGISTRATION: German Register for Clinical Trials, DRKS00019916, 26 November 2019.

The causal relationship between psoriasis and artificial joint re-operation after arthroplasty: A two-sample Mendelian randomization study.

BACKGROUND: Psoriasis is observationally associated with a higher risk of complications of arthroplasty; however, the causal effects of psoriasis on complications of arthroplasty are yet to be established. This study was to explore the causal effect of psoriasis on artificial joint re-operation after arthroplasty through two-sample Mendelian randomization (MR). METHODS: In the MR analysis, psoriasis was selected as the exposure in this study while single-nucleotide polymorphisms (SNPs) from a genome-wide association study (GWAS) were selected as the instrumental variables (IVs). Summary statistics data on artificial joint re-operation was extracted from publicly available GWAS data, including 218 792 European descent individuals. MR analysis was performed using the standard inverse variance weighted method (IVW). Furthermore, MR Egger, weighted median, simple mode, weighted mode, and the MR-PRESSO (Mendelian Randomization Pleiotropy Residual Sum and Outlier) test were also done to verify the results. Finally, the sensitivity analysis was executed. RESULTS: The IVW showed that psoriasis increases the risk of artificial joint re-operation (OR = 1.12; 95% CI = (1.01, 1.25); p = 0.036). This outcome was also verified by other methods including weighted median (OR = 1.16; 95% CI = (1.03, 1.31); p = 0.015), MR Egger (OR = 1.22; 95% CI = (1.03, 1.44); p = 0.038), and weighted mode (OR = 1.16; 95% CI = (1.03, 1.30); p = 0.025). No heterogeneity and directional pleiotropy were observed upon sensitivity analysis. CONCLUSION: The present study showed that psoriasis has a potential causal effect on artificial joint re-operation after arthroplasty. Further studies are warranted to elucidate the underlying mechanisms of causal associations between psoriasis on re-operation.

Proximal row carpectomy with interposition arthroplasty using both capsular flap and acellular human dermal matrix.

BACKGROUND: In cases of wrist arthritis, proximal row carpectomy (PRC) has been widely utilized and shown favorable long-term outcomes. However, its applicability is limited in cases where arthritis extends to the lunate fossa or capitate. Recently, surgical approaches combining various methods of interposition arthroplasty have been introduced to overcome these drawbacks. The purpose of this study was to perform PRC and interposition arthroplasty with dorsal capsule and acellular dermal matrix(ADM),and analyze the clinical outcomes of these procedures. METHODS: Fourteen cases who underwent PRC and interposition arthroplasty using both dorsal capsular flap and ADM were retrospectively recruited. The researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), retear, and radiocarpal distance (RCD). RESULTS: One year post-surgery, both the VAS pain scores, DASH scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the postoperative mean RCD was 4.8 ± 0.8 mm and one year follow up mean RCD was 3.6 ± 0.5 mm at one year post-surgery. Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases. CONCLUSION: The PRC and interposition arthroplasty with ADM demonstrated significantly improved clinical outcomes after surgery, showing a maintain of RCD without graft failure effectively.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study.

BACKGROUND: Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS: Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS: Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS: Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Clinical effect of modified anterolateral acromioarthroplasty during arthroscopic rotator cuff repair.

BACKGROUND: This study aimed to compare the clinical effect of modified anterolateral and traditional acromioplasty in arthroscopic rotator cuff repair. METHODS: The clinical data of 92 patients with total rotator cuff tears admitted to the Department of Joint Surgery of Jinhua Central Hospital from January 2016 to December 2019 were retrospectively analyzed. Among them, 42 patients underwent traditional acromioplasty during arthroscopic rotator cuff repair, and 50 underwent modified anterolateral acromioplasty. Patients were evaluated for preoperative and postoperative shoulder function, pain and critical shoulder angle, and incidence of rotator cuff re-tear at 12 months postoperatively. RESULTS: The preoperative general data of patients in the classic and modified anterolateral acromioplasty groups did not differ significantly (P > 0.05) and were comparable. The UCLA, ASES, and Constant shoulder joint scores were significantly improved in both groups. The VAS score was significantly decreased at 12 months postoperative than preoperative, with a statistically significant difference (P ≤ 0.05). Shoulder function and pain scores did not differ significantly between the two groups at 12 months postoperatively (P > 0.05). The CSA did not differ significantly between preoperative and postoperative 12 months in the traditional acromioplasty group (P > 0.05). However, 12 months postoperative CSA in the modified anterolateral acromioplasty group was significantly smaller than the preoperative CSA, with a statistically significant difference (P ≤ 0.05). The rates of rotator cuff re-tears were 16.67% (7/42) and 4% (2/50) in the two groups at 12 months postoperatively, respectively, with statistically significant differences (P ≤ 0.05). CONCLUSIONS: Traditional and modified anterolateral acromioplasty while treating total rotator cuff tears using arthroscopic rotator cuff repair significantly improves shoulder joint function. However, modified anterolateral acromioplasty significantly reduced the CSA value and decreased the incidence of rotator cuff re-tears.

Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review.

PURPOSE: To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR. METHODS: We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). RESULTS: We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency. CONCLUSIONS: There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Intravenous Tranexamic Acid Significantly Improved Visualization and Shortened the Operation Time in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis of Level I and II Studies.

PURPOSE: To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time. METHODS: We searched the PubMed, Cochrane Library, and Embase databases to find prospective randomized controlled clinical trials (RCTs) examining the use of TXA in ARCR. All included RCTs were evaluated for methodological quality using the Cochrane Collaboration's risk of bias tool. We used Review Manager 5.3 for meta-analysis and calculated the weighted mean difference (WMD) and 95% confidence interval (CI) of the related outcome indicators. The GRADE system was used to evaluate the strength of the clinical evidence provided by the included studies. RESULTS: Six RCTs (3 Level I, 3 Level II) from four countries or regions were included in this study: 2 studies used intra-articular (IA) TXA, and 4 studies used intravenous TXA. A total of 451 patients underwent ARCR, including 227 patients in the TXA group and 224 patients in the non-TXA group. In 2 RCTs evaluating good visualization, intravenous TXA achieved a better surgical field of view in ARCR compared to the control group (P =.036; P = .045). Meta-analysis showed that compared with non-TXA, intravenous TXA shortened the operation time (WMD = -12.87 min, 95% CI: -18.81 to -6.93). These two RCTs did not reveal a statistically significant difference in the impact of intravenous TXA and non-TXA on mean arterial pressure (MAP) (P = .306; P = .549). Compared with epinephrine (EPN), IA TXA had no significant effects on improving the visual field clarity under arthroscopy, shortening the operation time or reducing the total amount of irrigation fluid (P > .05). Compared with saline irrigation, IA TXA improved the surgical field of vision and shortened the operation time (P < .001). No adverse events were reported for either intravenous TXA or IA TXA. CONCLUSIONS: Intravenous TXA can shorten the operation time of ARCR, and the conclusions of existing RCTs suggest that intravenous TXA can improve visual field clarity during ARCR, thus supporting the application of intravenous TXA in ARCR. Compared with EPN, IA TXA was not better at improving the visual field clarity under arthroscopy and shortening the operation time, but it was better than saline irrigation. LEVEL OF EVIDENCE: Level II, systematic review and meta-analysis of Level I and II studies.

Revision and Conversion to Arthroplasty Are Low Among Adolescents Undergoing Meniscal Allograft Transplantation Using the Bridge-In-Slot Technique at Midterm Follow-Up.

PURPOSE: To report midterm outcomes after primary medial and lateral meniscal allograft transplantation (MAT) with fresh-frozen allografts implanted with the bridge-in-slot technique in the adolescent patient population. METHODS: Adolescent patients less than 18 years old at the time of primary MAT from 1999 to 2016 were retrospectively identified. International Knee Documentation Committee (IKDC) subjective form, Lysholm, and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales scores were collected before surgery and at 1-year, 2-year, and a minimum 5-year follow-up. Thresholds for achieving clinically significant outcomes were calculated, and the proportion of patients achieving minimal clinically important difference (MCID), patient-acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) was determined. Meniscus reoperation (partial, subtotal, or total meniscectomy, repair, or failure) and failure (revision MAT or conversion to arthroplasty) rates were determined. RESULTS: Forty-four (female n = 33; male n = 11) of 62 identified patients met inclusion criteria and were followed for a mean of 9.5 ± 3.8 years (range, 5.0-17.7). Lateral MAT was performed in most patients (n = 35/44 [80%]). Isolated MAT was performed in 27 (61%) patients. Common concomitant procedures included osteochondral allograft transplantation (32%), autologous chondrocyte implantation (18%), and anterior cruciate ligament reconstruction (14%). MCID, PASS, and SCB were achieved by patients at a minimum 5-year follow-up for IKDC (62%; 76%; 31%), Lysholm (62%; 79%; 23%), and KOOS questionnaires (Pain [65%; 81%; 41%], Symptoms [58%; 81%; 47%], Activities of Daily Living [53%; 77%; 35%], Sport [86%; 75%; 50%], and Quality of Life [59%; 81%; 59%]), respectively. Fourteen patients (32%) underwent reoperation at an average of 5.0 ± 4.3 years (range, 0.8-14.0) after MAT. Three (7%) patients met criteria for failure, requiring revision MAT an average of 3.8 ± 1.1 years (range, 2.8-4.9) after transplantation. No patients underwent arthroplasty. Overall survival free from failure at 1, 2, 5, and 10 years was 100%, 100%, 93%, and 93%, respectively. At the time of final follow-up, 80% of patients reported satisfaction with their current physical status. CONCLUSIONS: Primary MAT in adolescent patients resulted in significant and durable functional improvements at mid- to long-term follow-up. At an average of 9.5 years after surgery, meniscal reoperation rate was 32% whereas graft survival free of revision MAT was 93%. Adolescents undergoing MAT demonstrated similar functional outcomes and graft survivability when compared to available adult MAT literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Editorial Commentary: Polyurethane Meniscal Scaffold Could Serve as a Bridge to Meniscal Allograft or Arthroplasty in Carefully Selected Post-Meniscectomy Patients.

The young, active patient with pain after subtotal meniscectomy represents a troubling clinical situation with limited treatment options. "Post-meniscectomy syndrome" occurs at a rate of 4-25% and is defined as the presence of knee pain and functional limitations due to increased contact stresses and overload of the articular cartilage in a knee compartment, after subtotal or total meniscectomy. Meniscal allograft transplantation (MAT) can have reasonable results for some patients, typically under the age of 50, with no degenerative change, and no, or correctable instability or malalignment. However, MAT is expensive, it is often difficult to access meniscal allograft tissue, and the procedure can be technically challenging for the surgeon. Meniscal scaffolds have been commercially available and examined in small studies in the literature and metanalyses since the early 2000s. Generally, patients have shown clinical improvement with their use, but over time, they have shown signs of radiologic failure (decrease in size of the meniscal scaffold, meniscal extrusion on MRI, or other radiographic changes.) Nonetheless, recent research shows long-term survivorship of a polyurethane scaffold in some, carefully selected patients. While not shown to be chondroprotective, this could serve as a bridge to MAT or arthroplasty.

Editorial Commentary: Evidence for Patch Augmentation of Rotator Cuff Repair Is Weak.

Rotator cuff repair has a substantial failure rate despite various attempts to improve outcome and prevent a retear. Patch augmentation is an intuitively appealing approach to seek to reduce failure rate and improve outcomes for patients. Two main augmentation approaches are used: "on-lay" and "bridging." The literature is heterogeneous, and the best approach is uncertain. The evidence on patch augmentation for rotator cuff repair is both disparate and weak. Large randomized trials and registry data are required to move the field, ensure patient safety, and avoid wasting precious resources.

Editorial Commentary: One- and 2-Year Outcomes Are Clinically Similar After Rotator Cuff Repair: What Are We Waiting For?

Research standards require reliable data from which we can draw accurate conclusions. For short-term outcome studies, one measure recommended by journals is preferring at least 2 years' minimum follow-up. In some cases, this is important to avoid false conclusions because of follow-up too short to detect either failure or complete improvement. However, although intended to prevent an incomplete picture, this mandate may not always add clinical utility. Recent data suggest that for rotator cuff repair outcomes, 1-year follow-up is clinically sufficient, making the 2-year recommendation an inconvenient and unnecessary standard. The widely accepted 2-year benchmark may be arbitrary and promotes a one-size-fits all approach; the approach can be evidence-based refined.

Editorial Commentary: Subacromial Balloon Spacer Is an Alternative to Rotator Cuff Repair in Older, Lower-Demand Patients Who Prioritize Pain Relief and Faster Recovery Over Strength Restoration.

The subacromial balloon spacer was originally designed to treat massive irreparable rotator cuff tears in patients with pain but preserved function, and favorable results have been reported. However, surgeons have expanded its application to include use as an adjunct for salvage procedures such as superior capsular reconstruction and tendon transfer, as a delivery device for steroids or biologics, and as an augmentation in the setting of primary or revision rotator cuff tear. When adapting technology to new techniques, one must ask, What is the basis by which we can expect success? In rotator cuff repair, the technology of anchor, suture, and repair configurations is such that mechanical failure is rare. Failure occurs because of lack of biological healing. It is hard to imagine how the balloon may improve biology. In addition, an intact tendon is not required for acceptable patient function or pain relief. The balloon spacer is an alternative to repair in properly selected older, lower-demand patients who prioritize pain relief over strength restoration in exchange for faster recovery.

Editorial Commentary: Subacromial Balloon Spacer for Irreparable Rotator Cuff Tears Produces Clinical Improvement, Yet the Mechanism of Action Is Unclear.

Subacromial balloon spacers, a treatment option for massive irreparable rotator cuff tears, have been available in the United States since 2021 and much longer in Europe. The device has been described as a humeral head depressor that increases the subacromial space, centers the humeral head preventing superior migration, and improves deltoid mechanical advantage. This is not convincing. Balloon deflation occurs 3 months after implantation, eliminating the head-depressing effect, and the balloon fully degrades within 15 months. Some propose scarring in the subacromial space smoothes the acromial-humeral articulation; this is also unconvincing. The scar is not thick. Clinical studies largely report unchanged or worsened acromiohumeral interval after surgery. Short-term case series show improvement in pain and function, but comparative studies show mixed results. There may be some advantages over partial rotator cuff repair, but debridement alone may be sufficient treatment, and the generally positive short-term results do not determine whether symptom relief persists over the long term after balloon degradation. A recent clinical study does show mid-term improvement, but the mechanism remains unclear, and, if it is a result of smooth subacromial scarring, tuberoplasty may be an alternative.

Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations. METHODS: After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded. RESULTS: Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%. CONCLUSIONS: Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

High Fracture Rate of AVANTA Silicone Implant Following Arthroplasty of the Thumb MCP Joint of Rheumatoid Arthritis Patients with Boutonniere Deformities.

We retrospectively investigated the mid-term outcomes of arthroplasty using the AVANTA silicone implant for thumb metacarpophalangeal (MCP) joints with boutonniere deformity in patients with rheumatoid arthritis (RA). This study involved 36 thumbs of 33 RA patients with a mean follow-up period of 5.1 years (range, 2.0-13.3). Postoperatively, the mean extension was significantly increased and the mean flexion was significantly decreased (p<0.001, p<0.001, respectively), resulting in the mean arc of range of motion (ROM) shifting in the direction of extension after surgery. Implant fracture was observed in 10 thumbs (28%), and 4 of these (11%) underwent revision surgery. The survivorship with implant fracture and revision surgery as endpoints were 73.4% and 91.8% at 5 years, respectively. The preoperative arc of ROM and the postoperative flexion range of the implant-fracture group were significantly greater than those in the no-implant-fracture group (p=0.039, 0.034, respectively). These results suggest the importance of patient education and careful rehabilitation to prevent excessive flexion. Overall, the AVANTA silicone implant showed a relatively high rate of implant fracture at our institute.

Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

Humeral Head Reconstruction of Reverse Hill-Sachs Lesions.

Compared with anterior instability, posterior shoulder dislocations are a rare entity and are often missed at presentation. A concomitant anteromedial impression fracture of the humeral head, or a reverse Hill-Sachs lesion, is commonly present with these dislocations and is more pronounced with a longer timeline to reduction. Treatment of these defects ranges from nonsurgical treatment to soft-tissue procedures, bony reconstruction, and arthroplasty. Management may be dictated by various factors, such as patient demands, defect size and location, concomitant injuries, and underlying etiology. Small reverse Hill-Sachs defects without engagement can generally be treated nonsurgically or with benign neglect, whereas larger defects (>20%) often require surgery. The most reported surgical techniques are the (arthroscopic) McLaughlin and modified McLaughlin procedure, disimpaction and bone grafting, or reconstruction of the defect with autograft or with fresh (or fresh-frozen) osteochondral allograft. Finally, arthroplasty is generally required for large defects, where more than 45% to 50% of the articular cartilage is involved. Overall, reported outcomes generally reflect patient satisfaction for most patients, with a low incidence of secondary instability or posttraumatic arthritis, although better results are achieved when recognizing and treating these injuries in the more acute setting.

Proximal Humerus Fractures: How to Achieve Best Outcomes.

The treatment of proximal humerus fractures remains controversial. Although treatment modalities may vary, the goal of obtaining the best outcomes for patients remains the same. Most proximal humerus fractures can be treated nonsurgically but should still be managed actively. Deciding on surgical management requires a good understanding of indications and options. Indications for open reduction and internal fixation include younger or active patients with displaced two-, three-, and four-part fractures as well as fracture-dislocations with head-split patterns. Obtaining ideal outcomes requires anatomic reduction with restoration of the medial calcar as well as optimal position of implants to favor biomechanical stability. Reverse total shoulder arthroplasty is indicated for patients with severe and displaced fractures in older or low-demand patients. Obtaining the best functional outcomes depends on implant position, tuberosity healing, and early surgical intervention. Regardless of the treatment modality, these fractures can be challenging, and proper patient rehabilitation must be implemented. Future research will focus on patient selection and improving surgical techniques to maximize outcomes.

Infection in Shoulder Arthroplasty: Prevention, Diagnosis, and Treatment.

Prosthetic joint infection is a devastating complication following shoulder arthroplasty that can lead to pain, poor function, and poor quality of life. With the increasing number of shoulder arthroplasties performed annually, recognition of prosthetic infection and treatment is necessary. The skin surrounding the shoulder has a unique microbiome, and Cutibacterium acnes is the most commonly encountered bacteria causing prosthetic joint infection. C acnes is a low-virulence organism that resides in the subcutaneous layer of the skin. As a result, the clinical presentation is typically less obvious than prosthetic infections seen in other joints such as the hip and knee. Therefore, diagnosis is not always straightforward, and optimal treatment strategy is unclear. Guidance on prevention, diagnosis, and treatment of shoulder prosthetic joint infection with special emphasis on the consensus definition established at the 2018 International Consensus Meeting is provided.

How to avoid baseplate failure: the effect of compression and reverse shoulder arthroplasty baseplate design on implant stability.

BACKGROUND: Failure to achieve fixation of the glenoid baseplate will lead to clinical failure. The fixation of the baseplate to the scapula must be able to withstand sufficient shear forces to allow bony ingrowth. The importance of compression to neutralize the forces at the baseplate-bone interface has been assumed to be critical in limiting excessive micromotion. The purpose of this study is to determine the effect of compression on implant stability with different baseplate designs. METHODS: Various baseplate designs (1-piece monolithic central screw [1P], 2-piece locking central screw [2PL], and 2-piece nonlocking center screw [2PNL]) were investigated at 3 different compressive forces (high [810 N], medium [640 N], and low [530 N]). Synthetic bone cylinders were instrumented, and peripheral screws were used in all models. The combination of 1 locking and 3 nonlocking peripheral screw fixation was selected as worst-case scenario. Dynamic testing protocol followed the ASTM F2028-17 standard. The baseplate micromotion at high compression was compared to low compression. Additionally, the baseplate micromotion for each design was compared at baseline (first 50 cycles) and at 10,000 cycles for the 3 different compressive forces where motion above 150 µm was defined as failure. RESULTS: Baseplate micromotion was found to negatively correlate with compression (rpb = -0.83, P < .0001). At baseline, all baseplate designs were considered stable, regardless of compression. With high compression, average micromotion at the glenoid baseplate-bone interface remained below the 150-µm threshold for all baseplate designs at 10,000 cycles (1P: 50 ± 10 µm; 2PL: 78 ± 32 µm; 2PNL: 79 ± 8 µm; P = .060). With medium compression, average micromotion at 10,000 cycles for all 3 designs remained below the 150-µm threshold (1P: 88 ± 22 µm; 2PL: 132 ± 26 µm; 2PNL: 107 ± 39 µm). The 2PL design had the highest amount of micromotion (P = .013). With low compression, both 2-piece designs had an average micromotion above the 150-µm threshold whereas the 1-piece design did not (1P: 133 ± 35 µm; 2PL: 183 ± 21 µm; 2PNL: 166 ± 39 µm). The 2PL design had significantly higher micromotion when compared to 1P design (P = .041). DISCUSSION: The stability of a central screw baseplate correlates with the amount of compression obtained and is affected by implant design. For the same amount of compression, more micromotion is observed in a 2-piece design than a 1-piece design.