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Background: Postoperative dislocation is a known complication following reverse shoulder arthroplasty (RSA), but treatment patterns and outcomes remain unclear. The purpose of this study was to identify treatment patterns, rate of successful closed reductions, and factors associated with unsuccessful closed reductions for dislocations after RSA in a large multicenter patient cohort., Methods: A multicenter retrospective review was performed for patients receiving primary or revision RSA from June 2013 to May 2019 across fifteen institutions in the United States. Patients that sustained a postoperative shoulder dislocation (defined as complete loss of articulation between the humeral component and glenosphere confirmed on imaging) with a minimum of 3-month follow-up were included. The time from surgery to dislocation, nature of the dislocation, complications associated with the dislocation, initial treatment, success of closed reduction, recurrent dislocations, and subsequent treatments including revision procedures, were recorded. Univariate analysis was performed to identify patient factors associated with failure of an initial closed reduction attempt., Results: A cumulative postoperative dislocation incidence of 2.1% (n=138) was observed out of 6,621 patients undergoing RSA. The median time to dislocation was 7 weeks (interquartile range = 33 weeks), with 61.6% (n=85) occurring within the first 90 days after surgery. Initial treatment consisted of closed reduction (n=87, 63.0%), open reduction (n=1, 0.7%), revision arthroplasty (n=43, 31.2%), or benign neglect (n=7, 5.1%). Those treated without an initial closed reduction had higher incidence of associated complications (45.1% vs. 14.9%). Among patients initially treated with a closed reduction, 27 (31.0%) were successful (required no further interventions), 15 (17.2%) subsequently required a revision procedure, and 43 (49.4%) sustained an additional dislocation. The only patient or surgical factor associated with an unsuccessful closed reduction was increased BMI (31.8±6 vs. 28.9±5.2, P=0.02). Of the 43 patients that sustained an additional dislocation, 10 received another closed reduction and 30 received revision surgery. Among the 10 patients that received a second closed reduction, 5 remained stable (50.0%). Overall, 92 patients (66.7%) required a revision arthroplasty procedure during the study period, whereas 22 (22.5%) required multiple revision procedures. Ultimately, 18 patients (13.0%) remained unstable (benign neglect) at final follow-up., Conclusion: In this large multicenter series of postoperative dislocations following RSA, a closed reduction was initially attempted in the majority of patients, but only about one-third were successful and required no further intervention. Unsuccessful closed reductions were associated with higher patient BMI. Revision surgery for dislocations was complicated by a high rate of recurrent dislocations and re-revision surgery., (Copyright © 2024. Published by Elsevier Inc.)

Background: When implanting a cemented humeral stem, a reliable method to prevent inappropriate extension and enable pressurization of cement in the intramedullary canal is required. The aim was to assess the outcomes of a dedicated humeral diaphyseal cement restrictor., Methods: In total 218 shoulders (207 patients) were included in the study, all of whom underwent a cemented total shoulder arthroplasty and a retrospective review was performed. The primary outcomes of interest were device stability in the medullary canal, successful occlusion of the canal, cement extrusion and quality of cement mantle., Results: The majority of the cohort was female (63.3%) males and the average patient age was 71.7 years (SD 8.45). In 81.7% the device was deemed to be stable in the medullary canal. The device was significantly more stable in primary (84.2%) compared to revision cases (64.3%, p = 0.02). In 69.7% Barrack grade A mantle quality was achieved, this was higher in primary cases (74.2%) compared to revision cases (39.3%) (p = 0.00006)., Discussion: We noted excellent cementation outcomes using a cement restrictor specifically designed for the diaphyseal humerus anatomy. However, this humeral specific restrictor was noted to be more stable in primary as compared to revision cases., Competing Interests: Author GEG would like to declare the following potential conflicts of interest American Shoulder and Elbow Surgeons: Committee member, Arthroscopy Association of North America: Committee member, Academic Orthopaedic Consortium: Associate Chief medical officer, Enovis/DJO: IP royalties; Other financial or material support; Paid consultant; Paid presenter or speaker, Elsevier: Textbook royalties for “Skeletal Trauma of the Upper Extremity.”, Aevumed: Stock or stock options, Genesys: Stock or stock options, Sparta: Stock or stock options, CultivateMD: Stock or stock options, Patient IQ: Stock or stock options, Journal of Shoulder and Elbow Surgery: Editorial or governing board, Restor3d: Paid consultant; Stock, Mitek/DePuy: Paid consultant, Stryker/Tornier: IP royalties; Paid consultant, ROM 3: Stock or stock options. Author TEL would like to declare the following consultant for Lima and Tornier; IDE and author OAA would like to declare the following, consultant for Lima, Exactech, Responsive Arthroscopy and Smith & Nephew. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation., Methods: Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons., Results: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively)., Conclusion: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Historically, the wind-up delivery is considered a more biomechanically advantageous pitching motion compared to the stretch. Recently, some pitchers have shifted to pitching exclusively from the stretch regardless of the game situation. The goal of this study was to compare temporal, kinematic and kinetic variables between the wind-up and stretch deliveries. Professional pitchers ( n  = 52, 189.1 ± 4.8 cm, 92.8 ± 8.4 kg) threw fastballs evaluated by 3D-motion capture (480 Hz) from both the wind-up and stretch deliveries. Within a pitcher, there was no significant difference in ball velocity between the two deliveries ( p  = 0.15). The stretch delivery was significantly quicker to ball release at toe off 2 ( p  < 0.001) (the last frame the pitcher's foot contacts the ground before progressing to maximum knee height) and maximum knee height ( p  < 0.001). The majority of differences occurred prior to foot contact. The wind-up delivery produced greater maximum shoulder external rotation ( p  < 0.001) and lead knee flexion at ball release ( p  < 0.001). Pitching from the stretch incurred greater shoulder superior force ( p  < 0.001). It remains unknown if this is clinically significant as pooled means show only a 2% difference. Therefore, pitching a fastball from either the wind-up or stretch delivery provides comparable mechanics and throwing arm load with likely comparable risk of injury.

Background: Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty., Methods: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 RESULTS: A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90 th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90 th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90 th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001)., Conclusion: Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016., (Copyright © 2024. Published by Elsevier Inc.)

Background: Although both anatomic (ATSA) and reverse total shoulder arthroplasty (rTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely among providers. Although surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant., Methods: A national database was queried to identify surgeons performing ATSA and rTSA. For all surgeons who performed more than 10 cases between 2010 and 2022, fellowship data were individually collected via an online search. For each fellowship group, rates of ATSA and rTSA were identified using International Classification of Diseases procedural codes. Those who underwent revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSAs and rTSAs by fellowship in addition to the rate of rTSA performed for a primary diagnosis of glenohumeral osteoarthritis., Results: A total of 131,974 patients met the inclusion criteria and were retained for this study. The proportion of rTSAs increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary rTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose rTSA more frequently for the diagnosis of glenohumeral osteoarthritis than Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than rTSA in comparison with surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in the percentage of all shoulder arthroplasty procedures from 2010 to 2022 (28.4%-40.4%), whereas the Other group decreased by a comparable amount (45.9%-32.4%) over the same period., Conclusions: Surgeons who have completed a Sports Medicine fellowship choose rTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSAs in their arthroplasty practice. Revision ATSA and revision rTSA represent a larger percentage of overall case volume for Shoulder and Elbow surgeons., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: When the lead leg of a pitcher contacts the ground, the knee braces and then rapidly extends, initiating energy transfer to begin pelvis and trunk rotation., Purpose: To investigate the relationship of lead knee extension during the pitching delivery with peak lead knee extension velocity, ball velocity, and elbow varus torque in high school and professional pitchers., Study Design: Descriptive laboratory study., Methods: Data from 50 professional (PRO) and 50 high school (HS) pitcher groups were retrospectively analyzed. Pitchers threw 8 to 12 fastballs under 3-dimensional motion analysis (480 Hz). The groups were divided according to high or low lead knee extension: PRO-high (n = 18), PRO-low (n = 16), HS-high (n = 16), and HS-low (n = 17). Lead knee flexion, lead knee extension velocity, ball velocity, and elbow varus torque were analyzed between groups. Regression analyses were performed to quantify associations between lead knee extension and ball velocity and elbow varus torque for all pitchers., Results: At foot contact, all pitchers landed with similar knee flexion. PRO-high and HS-high pitchers had significantly greater lead knee extension through remaining pitching time points compared with the PRO-low and HS-low pitchers. PRO-high pitchers had faster ball velocity than PRO-low pitchers (39.8 ± 1.1 vs 39.3 ± 1.3 m/s, respectively), and HS-high pitchers had faster ball velocity than HS-low pitchers (34.1 ± 2.6 vs 31.2 ± 1.8 m/s, respectively) ( P < .05). PRO-high pitchers had decreased elbow varus torque compared with PRO-low pitchers (85.3 ± 10.7 vs 95.4 ± 13.3 N·m, respectively); conversely, HS-high pitchers had greater elbow varus torque than HS-low pitchers (64.2 ± 14.7 vs 56.3 ± 12.2 N·m, respectively). For every 1° increase in lead knee extension, ball velocity increased by 0.47 m/s ( P < .001) and elbow varus torque increased by 0.27 N·m ( P = .025)., Conclusion: Proper lead knee extension allowed efficient energy transfer through the kinetic chain to produce optimal ball velocity and minimize elbow varus torque in professional pitchers. Conversely, while proper lead knee extension improved ball velocity among high school pitchers, this did not minimize elbow varus torque., Clinical Relevance: Professional pitchers can extend their lead knee with minimal impact at the elbow. In high school pitchers, cognizance of proper full-body pitching mechanics remains a priority over increased velocity., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.M.B. has received education support from Smith+Nephew and hospitality payments from Exactech. N.N.V. has received consulting fees from Arthrex and Stryker; nonconsulting fees from Arthrex; royalties from Arthrex, Smith+Nephew, and Graymont Professional Products; and hospitality payments from Spinal Simplicity and Relievant Medsystems. G.E.G. has received education payments from Medwest; consulting fees from DePuy Synthes/Medical Device Business Services, Encore Medical, Stryker, Wright Medical, and Bioventus; royalties from Encore Medical, Stryker, and Wright Medical; and honoraria from Wright Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Purpose: Cervical total disc replacement (cTDR) has been established as an alternative treatment for degenerative cervical radiculopathy and myelopathy. While the rate of complications for cTDR is reasonably low, recent studies have focused on bone loss after cTDR. The purpose of this work is to develop a clinical management plan for cTDR patients with evidence of bone loss. To guide our recommendations, we undertook a review of the literature and aimed to determine: (1) how bone loss was identified/imaged, (2) whether pre- or intraoperative assessments of infection or histology were performed, and (3) what decision-making and revision strategies were employed., Methods: We performed a search of the literature according to PRISMA guidelines. Included studies reported the clinical performance of cTDR and identified instances of cervical bone loss., Results: Eleven case studies and 20 cohort studies were reviewed, representing 2073 patients with 821 reported cases of bone loss. Bone loss was typically identified on radiographs during routine follow-up or by computed tomography (CT) for patients presenting with symptoms. Assessments of infection as well as histological and/or explant assessment were sporadically reported. Across all reviewed studies, multiple mechanisms of bone loss were suspected, and severity and progression varied greatly. Many patients were reportedly asymptomatic, but others experienced symptoms like progressive pain and paresthesia., Conclusion: Our findings demonstrate a critical gap in the literature regarding the optimal management of patients with bone loss following cTDR, and treatment recommendations based on our review are impractical given the limited amount and quality evidence available. However, based on the authors' extensive clinical experience, close follow-up of specific radiographic observations and serial radiographs to assess the progression/severity of bone loss and implant changes are recommended. CT findings can be used for clinical decision-making and further follow-up care. The pattern and rate of progression of bone loss, in concert with patient symptomatology, should determine whether non-operative or surgical intervention is indicated. Future studies involving implant retrieval, histopathological, and microbiological analysis for patients undergoing cTDR revision for bone loss are needed., (© 2024. The Author(s).)

Purpose: To evaluate the extent to which experienced reviewers can accurately discern between artificial intelligence (AI)-generated and original research abstracts published in the field of shoulder and elbow surgery and compare this with the performance of an AI detection tool., Methods: Twenty-five shoulder- and elbow-related articles published in high-impact journals in 2023 were randomly selected. ChatGPT was prompted with only the abstract title to create an AI-generated version of each abstract. The resulting 50 abstracts were randomly distributed to and evaluated by 8 blinded peer reviewers with at least 5 years of experience. Reviewers were tasked with distinguishing between original and AI-generated text. A Likert scale assessed reviewer confidence for each interpretation, and the primary reason guiding assessment of generated text was collected. AI output detector (0%-100%) and plagiarism (0%-100%) scores were evaluated using GPTZero., Results: Reviewers correctly identified 62% of AI-generated abstracts and misclassified 38% of original abstracts as being AI generated. GPTZero reported a significantly higher probability of AI output among generated abstracts (median, 56%; interquartile range [IQR], 51%-77%) compared with original abstracts (median, 10%; IQR, 4%-37%; P < .01). Generated abstracts scored significantly lower on the plagiarism detector (median, 7%; IQR, 5%-14%) relative to original abstracts (median, 82%; IQR, 72%-92%; P < .01). Correct identification of AI-generated abstracts was predominately attributed to the presence of unrealistic data/values. The primary reason for misidentifying original abstracts as AI was attributed to writing style., Conclusions: Experienced reviewers faced difficulties in distinguishing between human and AI-generated research content within shoulder and elbow surgery. The presence of unrealistic data facilitated correct identification of AI abstracts, whereas misidentification of original abstracts was often ascribed to writing style., Clinical Relevance: With rapidly increasing AI advancements, it is paramount that ethical standards of scientific reporting are upheld. It is therefore helpful to understand the ability of reviewers to identify AI-generated content., Competing Interests: Disclosures All authors (R.D.S., S.Y.S., M.A.M., P.J.D., X.A.D., G.E.G., C.S.K., J.C.L., S.N., J.S-S., M.E.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: In 2020, the American Society of Shoulder and Elbow Therapists (ASSET) published an evidence-based consensus statement outlining postoperative rehabilitation guidelines following anatomic total shoulder arthroplasty (TSA)., Purpose: The purpose of this study was to (1) quantify the variability in online anatomic TSA rehabilitation protocols, and (2) assess their congruence with the ASSET consensus guidelines., Methods: This study was a cross-sectional investigation of publicly available, online rehabilitation protocols for anatomic TSA. A web-based search was conducted in April 2022 of publicly available rehabilitation protocols for TSA. Each collected protocol was independently reviewed by two authors to identify recommendations regarding immobilization, initiation, and progression of passive (PROM) and active range of motion (AROM), as well as the initiation and progression of strengthening and post-operative exercises and activities. The time to initiation of various components of rehabilitation was recorded as the time at which the activity or motion threshold was permitted by the protocol. Comparisons between ASSET start dates and mean start dates from included protocols were performed., Results: Of the 191 academic institutions included, 46 (24.08%) had publicly available protocols online, and a total of 91 unique protocols were included in the final analysis. There were large variations seen among included protocols for the duration and type of immobilization post-operatively, as well as for the initiation of early stretching, PROM, AROM, resistance exercises, and return to sport. Of the 37 recommendations reported by both the ASSET and included protocols, 31 (83.78%) were found to be significantly different between groups (p\<0.05)., Conclusion: Considerable variability was found among online post-operative protocols for TSA with substantial deviation from the ASSET guidelines. These findings highlight the lack of standardization in rehabilitation protocols following anatomic TSA., Level of Evidence: 3b., Competing Interests: There are no financial biases or conflicts of interest for any author related to this study. The study was exempt from International Review Board approval as no identifiable patient information was used., (© The Author(s).)

Background: The purpose of this study is to assess the current trends in fellowship training, career satisfaction, practice characteristics, and surgical case volume among shoulder and elbow surgeons., Methods: A web-based, anonymous 25-item survey was sent to the membership of the American Shoulder and Elbow Surgeons (ASES) in October of 2022. Questions posed included respondent demographics, fellowship training, career satisfaction, practice characteristics, and surgical case characteristics. Descriptive statistics were performed to report demographic information, assess job and training satisfaction rates, and evaluate practice characteristics. Chi-squared and independent samples t-tests were performed to analyze satisfaction rates, job applications, and surgical case volume with regard to years in practice and practice setting., Results: Twenty percent (243/1248) of ASES members satisfactorily completed the survey. Of the 243 ASES member respondents, 97% (236/243) stated that they would pursue their fellowship training again. Ninety-eight percent (239/243) of respondents were satisfied with their specialty choice. One-hundred percent (242/243) were satisfied with their training in shoulder. Seventy-two percent (176/243) were satisfied with their training in elbow. Seventy-four percent (179/243) were satisfied with their job availability and 85% (207/243) were satisfied with their job location. The mean total number of orthopedic surgical cases per year was 393 ± 171. The mean total number of shoulder cases per year was 253 ± 149. The mean total number of elbow cases per year was 41 ± 41. Physicians who have been in practice for 11 years or more were comparatively more satisfied (90% vs. 80%) with their job location (P value = .008) and job availability (81% vs. 64%, P value < .001). Additionally, senior surgeons completed more orthopedic (431 vs. 347, P value < .001) and shoulder (279 vs. 220, P value = .002) cases annually than surgeons earlier in their careers. Satisfaction rates, job applications, and surgical case volume did not associate with practice setting., Conclusions: The majority of ASES member shoulder and elbow surgeons are satisfied with their training, their case volume and complexity, and their specialty choice. Fewer surgeons are satisfied with their elbow training and overall elbow case volume remains low among shoulder and elbow surgeons. Shoulder and elbow surgeons earlier in their careers perform fewer surgical cases, are less satisfied with their job availability and location, and completed more job applications for their first job after fellowship when compared to more senior surgeons., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown., Methods: The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at P ≤ .00023., Results: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort., Conclusion: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Suprascapular nerve (SSN) entrapment is a rare but significant cause of posterior shoulder pain and weakness. Compression of the nerve at the level of the spinoglenoid notch leads to weakness and atrophy of the infraspinatus. A detailed history and physical examination along with appropriate workup are paramount to arrive at this diagnosis. Surgical decompression is indicated in cases refractory to conservative management. In this Technical Note, we describe our technique for open decompression of the SSN at the spinoglenoid notch. This approach permits direct visualization of the SSN and allows for a safe, reliable, and thorough decompression., (© 2024 The Authors.)

Purpose: To compare the biomechanical performance of a suture with proposed dynamic self-tensioning properties with that of commonly used high-tensile sutures by evaluating suture loop length changes, responses to cyclic loading, and failure testing with intermittent saline soaks., Methods: Six knots each of 4 different sutures were studied: 3 high-tensile sutures (ORTHOCORD, FiberWire, and ETHIBOND), and a dynamically self-tensioning suture (DYNACORD). After we measured loop length, knots were soaked in 37°C saline for 24 hours. Loop lengths were remeasured and tensile testing was performed. Cyclic elongation, first-cycle excursion, and elongation amplitude were recorded. Knots were then resoaked and retested. Finally, knots were pulled to failure, and peak load and stiffness were measured. Values were compared using nonparametric statistical tests., Results: DYNACORD loop length decreased by 27% after the first soak ( P  = .002), whereas the other sutures demonstrated no length change ( P > .05). Although DYNACORD loop length increased during cyclic load testing ( P  = .009), it was still significantly reduced after the second saline soak compared with its initial length ( P  = .002), whereas all other suture loops had elongated. ETHIBOND ( P  = .004) and ORTHOCORD ( P  = .002) had significantly less cyclic elongation from cycle I to cycle II testing compared with the other sutures. ETHIBOND had the lowest peak load at failure ( P  = .002). FiberWire had the greatest stiffness ( P  = .006)., Conclusions: Compared with other suture types, the self-tensioning suture showed dynamic properties, demonstrating a decrease in loop length when soaked in a saline bath. This length was maintained after a second soak despite increased loop length during interval cyclic loading., Clinical Relevance: Knot and loop security are of paramount importance to arthroscopic soft-tissue procedures. The ability for a suture to self-tension has implications for how it may interact with tissues in vivo to increase construct stability after arthroscopic soft tissue repair procedures., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A DePuy-Mitek research grant was used to fund this study. N.M. reports grants from DePuy-Mitek, during the conduct of the study. E.S. reports grants from DePuy-Mitek, during the conduct of the study. S.A. reports grants from DePuy-Mitek, during the conduct of the study. S.L. reports grants from DePuy-Mitek, during the conduct of the study. N.L. reports grants from DePuy-Mitek, during the conduct of the study. B.D. reports grants from DePuy-Mitek, during the conduct of the study. J.C. reports grants from DePuy-Mitek, during the conduct of the study, and other from Arthrex, outside the submitted work. G.N. reports grants from DePuy-Mitek, during the conduct of the study. G.G. reports grants from DePuy-Mitek, during the conduct of the study, and other from DePuy-Mitek, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Purpose: To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability., Methods: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement., Results: Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization., Conclusions: The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required., Level of Evidence: Level V, expert opinion., Competing Interests: Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M.T.P. reports board or committee member for AAOS, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, Society of Military Orthopaedic Surgeons, Society of Military Orthopaedic Surgeons, Arthrex, and SLACK Inc; editorial or governing board for Arthroscopy, Knee, and San Diego Shoulder Institute; IP royalties; paid consultant; research support for Arthrex; IP royalties from Arthrosurface; Publishing royalties, financial or material support from Elsevier; paid consultant Joint Restoration Foundation (AlloSource): and publishing royalties, financial, or material support from SLACK Inc. B.W. reports board or committee member for AAOS, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America; other financial or material support and paid presenter or speaker from Arthrex; editorial or governing board, publishing royalties, and financial or material support from Arthroscopy; publishing royalties and financial or material support from Elsevier; paid consultant for FH Ortho: stock or stock options and unpaid consultant for Kaliber AI; other financial or material support from the Musculoskeletal Transplant Foundation and Smith & Nephew; paid presenter or speaker; stock or stock options; unpaid consultant for Sparta; paid presenter or speaker for Vericel; editorial or governing board for Video Journal of Sports Medicine; and stock or stock options from Vivorte. B.E. reports board or committee member for AAOS, American Orthopaedic Society for Sports Medicine, and American Shoulder and Elbow Surgeons; paid consultant for and research support from Arthrex; and research support from DePuy, A Johnson & Johnson Company, Linvatec, Smith & Nephew, and Stryker. C.K. reports paid consultant for Acumed, Restore3d, and Smith & Nephew; and stock or stock options from GE Healthcare, Johnson & Johnson, Merck, and Pfizer. A.I. reports board or committee member for AGA, DGOOC, DGOU, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS); editorial or governing board for AOSSM, Archives of Orthopaedic and Trauma Surgery, Arthroscopy, Arthroskopie Springer, Journal of Shoulder and Elbow Surgery, Knee Surgery, Sports Traumatology, Arthroscopy, Knee Surgery, Sports Traumatology, Arthroscopy, and OOTR; IP royalties and research support from Arthrex; IP royalties from Arthrosurface: paid consultant for Arthrosurface, medi Bayreuth; and publishing royalties, financial or material support Saunders/Mosby-Elsevier and Springer, Thieme. B.O. reports editorial or governing board for Orthopedics and Orthopedics Today; editorial or governing board and publishing royalties, financial or material support from American Journal of Sports Medicine; board or committee member of the American Orthopaedic Society for Sports Medicine; research support from Arthrex; IP royalties and paid consultant for CONMED Linvatec; paid consultant and research support from Mitek; research support from Musculoskeletal Transplant Foundation; publishing royalties and financial or material support from Saunders/Mosby-Elsevier, SLACK Inc, and Springer; paid consultant for Vericel; and stock or stock options from Vivorte. D.T. reports board or committee member for American Orthopaedic Society for Sports Medicine; editorial or governing board of OJSM; IP royalties from DePuy, A Johnson & Johnson Company; research support from Smith & Nephew; and other financial or material support from Arthrex, Breg, DJOrtho, Mitek, and Smith & Nephew. A.T. reports board or committee member for American Orthopaedic Society for Sports Medicine; and other financial or material support from Arthrex, Breg, Mitek, Smith & Nephew, and Stryker. F.C. reports board or committee member for American Shoulder and Elbow Surgeons; IP royalties from and paid consultant for Arthrex; and publishing royalties, financial or material support from Saunders/Mosby-Elsevier and Wolters Kluwer Health - Lippincott Williams & Wilkins. P.M. reports IP royalties from, research support from, and paid consultant for Arthrex; research support from Canon, DJ Orthopaedics, Icarus Medical, Ossur, Siemens, Smith & Nephew, Stryker, SubioMed, and Wright Medical Technology; and stock or stock Options from VuMedi. B.M. reports board or committee member for Arthroscopy Association of North America; paid consultant for Arthrex; and paid presenter or speaker for Pendopharm. O.A. reports paid consultant for Exactech, LIMA, Responsive Arthroscopy, and Smith & Nephew and stock or stock options from Suture Tech. H.M. reports paid presenter or speaker for CONMED Linvatec and DJ Orthopaedics; and board or committee member for the Irish Orthopaedic Association. J.S-S. reports paid consultant for Acumed; board or committee member for American Shoulder and Elbow Surgeons; publishing royalties and financial or material support from Elsevier; paid consultant for Exactech; editorial or governing board and publishing royalties, financial or material support from the Journal of Shoulder and Elbow Surgery; publishing royalties and financial or material support from Oxford University Press; stock or stock options from Orthobullets, Precision OS, and posterior shoulder instability: Stock or stock Options; and IP royalties, paid presenter or speaker, research support from Stryker. P.D. reports board or committee member for American Shoulder and Elbow Surgeons and Arthroscopy Association of North America; IP royalties; paid consultant; paid presenter or speaker; research support for Arthrex; stock or stock options for Kaliber Labs and PT Genie; and editorial or governing board of Orthopedics Today. I.W. reports research support from Aesculap/B.Braun and Arthrex; editorial or governing board of the American Journal of Sports Medicine (AJSM) and Arthroscopy; board or committee member for the American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Canadian Orthopaedic Association, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and International Society of Orthopaedic Surgery and Traumatology (Société Internationale de Chirurgie Orthopédique et de Traumatologie, SICOT); paid presenter or speaker for Bioventus and DePuy, A Johnson & Johnson Company; paid presenter or speaker and research support from Linvatec and Smith & Nephew. T.L. reports research support from Arthrex; other financial or material support from Lima; paid consultant for Stryker; and research support from Wright Medical Technology. R.M.F. reports board or committee member of AAOS, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America, International Cartilage Restoration Society, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; editorial or governing board of the Journal of Shoulder and Elbow Surgery and Orthopedics Today; paid consultant; paid presenter or speaker for AlloSource and JRF; paid consultant, paid presenter or speaker, and research support from Arthrex; publishing royalties, financial or material support from Elsevier; paid presenter or speaker for Ossur, and research support from Smith & Nephew. G.A. reports board or committee member of American Shoulder and Elbow Surgeons; IP royalties from CONMED Linvatec, Exactech, and Wright Medical Technology; editorial or governing board of the Journal of Shoulder and Elbow Surgery; stock or stock options from Parvizi Surgical Innovation, PrecisionOS, and Reach Orthopedics; and IP royalties, paid consultant, and research support from Stryker. S.R. reports stock or stock options from Ortho RTI and paid consultant for Teladoc. J.Y.B. reports board or committee member of AAOS, Mid-American Orthopaedic Association, and Ohio Orthopaedic Society; research support from Arthrex; paid consultant for CONMED Linvatec and Stryker; and paid consultant for and Research support from Smith & Nephew. R.H.B. reports board or committee member of AAOS and American Orthopaedic Association; and editorial or governing board of the American Journal of Sports Medicine and Journal of the American Academy of Orthopaedic Surgeons. E.C. reports board or committee member of the European Society for Surgery of the Shoulder and Elbow and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; paid presenter or speaker for DePuy, A Johnson & Johnson Company, and Smith & Nephew; paid consultant for Johnson & Johnson; editorial or governing board of the Journal of Shoulder and Elbow Surgery; and paid presenter or speaker and research support from Stryker. C.C. reports paid consultant for Arthrex; research support from Major League Baseball; and publishing royalties and financial or material support from Springer. P.N.C. reports IP royalties, paid consultant, and paid presenter or speaker for DePuy, A Johnson & Johnson Company; paid consultant for DJ Orthopaedics; IP royalties from and paid consultant for Exactech; publishing royalties and financial or material support from the Journal of Shoulder and Elbow Surgery; IP royalties from Responsive Arthroscopy; paid consultant for Smith & Nephew; and stock or stock options for TitinKM Biomedical. R.A.D. reports unpaid consultant for Akunah; other financial or material support from Arthrex GmbH, Lynch Medical Supplies (Arthrex distributor), and Tekno Surgical (Stryker distributor); stock or stock options from Beemed; board or committee member of the Irish Shoulder and Elbow Society and Société Européenne pour la Chirurgie de l’Epaule et du Coude (SECEC); editorial or governing board of the Journal of the American Academy of Orthopaedic Surgeons; paid consultant for Precision OS; paid presenter or speaker for Smith & Nephew; and paid consultant and paid presenter or speaker for Stryker. X.A.D. reports board or committee member of the American Shoulder and Elbow Surgeons and Association of Bone and Joint Surgeons; editorial or governing board of Clinical Orthopaedics and Related Research; and paid presenter or speaker for Smith & Nephew; S.J.F. reports paid presenter or speaker for Anika Therapeutics; and paid consultant for Zimmer. M.T.F. reports board or committee member of the AAOS, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; paid consultant for Biorez; research support and unpaid consultant for CONMED Linvatec; research support from Major League Baseball, National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases and Eunice Kennedy Shriver National Institute of Child Health and Human Development), and Regeneration Technologies; IP royalties, paid consultant, paid presenter or speaker, and research support from Smith & Nephew; stock or stock options and unpaid consultant for Sparta; and paid consultant for Tornier. D.E.G. reports IP royalties from Pattern Health. P.R.H. reports board or committee member of the AGA-German speaking Arthroscopy Association. G.H. reports research support from Arthrex; paid consultant and research support from DePuy, A Johnson & Johnson Company: editorial or governing board of the Journal of Science and Medicine in Sport and Shoulder and Elbow (Wiley): research support from Medartis; and board or committee member of the Shoulder Elbow Society of Australia. E.I. reports editorial or governing board of the American Journal of Sports Medicine and Journal of Shoulder and Elbow Surgery. B.C.L. reports board or committee member of the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America; research support from Arthrex and Wright Medical Technology; and paid consultant for DePuy, A Johnson & Johnson Company, and Miach. R.M. reports stock or stock Options from Alignmed; and paid presenter or speaker for Arthrex. L.E.L. reports editorial or governing board of the American Journal of Sports Medicine and Arthroscopy, and Video Journal of Sports Medicine; and board or committee member of the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America. W.N.L. reports IP royalties from and unpaid consultant for Zimmer. E.C.M. reports board or committee member of the American Orthopaedic Society for Sports Medicine and research support from Arthrex. M.E.M. reports board or committee member of the American Shoulder and Elbow Surgeons and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; IP royalties from and paid consultant for Biomet: paid consultant for Bioventus; research support for Breg, DJ Orthopaedics, Mitek, Ossur, and Smith & Nephew; publishing royalties, and financial or material support from Elsevier; editorial or governing board of Orthopedics Today and Orthopedics American Journal of Sports Medicine; and IP royalties from Zimmer. P.M. reports IP royalties and stock or stock options from Alyve Medical: IP royalties, paid presenter or speaker, and research support from Arthrex; and IP royalties from Medacta. L.N. reports paid consultant from; Arthrex board or committee member of the European Society for Shoulder and Elbow Surgery; stock or stock options from Sparta Biopharma and Statera; and IP royalties from and Paid consultant for Stryker. G.N. reports board or committee member of the American Shoulder and Elbow Surgeons and editorial or governing board of Obere Extremität/Springer; IP royalties from Anika and Innomed; paid presenter or speaker for Arthrosurface; paid consultant for AzurMed; IP royalties from and paid consultant for Stryker; and research support form Tornier. M.J.O. reports stock or stock options from Aevumed; board or committee member for the American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, and the Southern Orthopaedic Association; paid consultant for Exactech and Wright Medical Technology; and paid consultant for and research support from Smith & Nephew. S.A.P. reports board or committee member for the AAOS and American Shoulder and Elbow Surgeons; paid consultant for Arthrex and paid consultant for and research support from Exactech. J.P.S. reports editorial or governing board of Arthroscopy. N.A.T. reports paid presenter or speaker for DJ Orthopaedics. E.R.W. reports paid consultant for Acumed, Biomet, Osteoremedies, and Stryker and research support from Konica Minolta. J.R.W. reports board or committee member for the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America; paid presenter or speaker for Arthrex and Vericel; paid consultant for Geistlich and ogy; editorial or governing board for Ortho Info; and stock or stock options for Viewfi. J.S.H. reports board or committee member for the American Shoulder and Elbow Surgeons and IP royalties and paid consultant for DJ Orthopaedics. L.M.J. reports research support from Arthrex, Mitek, and Smith & Nephew; editorial or governing board for the Bulletin for the Hospital for Joint Diseases and JBJS Reviews; stock or stock options from Lazurite: and publishing royalties, financial or material support from Wolters Kluwer Health - Lippincott Williams & Wilkins. A.L. reports paid consultant; paid presenter or speaker for Arthrex; stock or stock options from BeeMed and Follow Health; paid consultant; paid presenter or speaker; research support; stock or stock options from Medacta: board or committee member of the Société Francaise d'Arthroscopie; and IP royalties; paid consultant; paid presenter or speaker for Wright Medical Technology. G.E.G. reports stock or stock options from Aevumed, CultivateMD, Genesys, Patient IQ, ROM 3, and Sparta Biopharma; IP royalties; other financial or material support; paid consultant; paid presenter or speaker for DJ Orthopaedics: publishing royalties, financial or material support from Elsevier; paid consultant for Mitek; paid consultant; stock or stock options from Restor3d: and IP royalties from and paid consultant for Tornier. J.F.D. reports board or committee member for AAOS, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Society of Military Orthopaedic Surgeons; and editorial or governing board for American Journal of Sports Medicine. S.N. reports paid consultant for ACI Clinical and Synthes; IP royalties; stock or stock options from Aevumed and MediFlix; board or committee member of American Shoulder and Elbow Surgeons and Philadelphia Orthopaedic Society; IP royalties; paid consultant; paid presenter or speaker for Biederman Motech; stock or stock options from CLEU Diagnostics, Coracoid Solutions, HealthExl, Parvizi Surgical Innovations, and SurgiWipe; IP royalties; paid consultant; paid presenter or speaker; research support from Enovis; editorial or governing board of the Journal of Bone and Joint Surgery - American and Shoulder & Elbow; publishing royalties, financial or material support from Saunders/Mosby-Elsevier, SLACK Inc, and Wolters Kluwer Health - Lippincott Williams & Wilkins: research support from Roche, Arthrex, DePuy, A Johnson & Johnson Company, Smith & Nephew, Stryker, and Zimmer; and IP royalties from Tigon. C.S.K. reports paid consultant for Acumed, Restore3d, and Smith & Nephew and stock or stock options from GE Healthcare, Johnson & Johnson, Merck, and Pfizer. O.A. reports paid consultant for Exactech, LIMA, Responsive Arthroscopy, and Smith & Nephew and stock or stock options from Suture Tech. Y.B-A. reports paid presenter or speaker from DJ Orthopaedics and stock or stock options from K2M. J.M.L. reports stock or stock options from Stryker and Zimmer. All other authors (E.T.H., Z.S.A., T.R.D., L.P., D.B.W., K.E.B., N.M.C., T.D., J.R.W., M.R., B.W.H., K.G.K., L.A.R., N.P., L.E., T.C., R.M.D., T.B.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/H904).

Background: Approximately 90% of patients who undergo arthroscopic rotator cuff repair (RCR) are satisfied with their pain levels and function after surgery. However, a subset of patients experience continued symptoms that warrant revision surgery. Preoperative risk factors for RCR failure requiring revision surgery have not been clearly defined., Purpose: To (1) determine the rate of RCR failure requiring revision surgery and (2) identify risk factors for revision surgery, which will help surgeons to determine patients who are at the greatest risk for RCR failure., Study Design: Systematic review and meta-analysis; Level of evidence, 4., Methods: A systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were performed. The initial search resulted in 3158 titles, and 533 full-text articles were assessed for eligibility. A total of 10 studies met the following inclusion criteria: (1) human clinical studies, (2) arthroscopic RCR, (3) original clinical research, and (4) evaluation of preoperative risk factors for revision., Results: After a full-text review, a total of 16 risk factors were recorded and analyzed across 10 studies. Corticosteroid injection was the most consistent risk factor for revision surgery, reaching statistical significance in 4 of 4 studies, followed by workers' compensation status (2/3 studies). Patients with corticosteroid injections had a pooled increased risk of revision surgery by 47% (odds ratio, 1.44 [95% CI, 1.36-1.52]). Patients with workers' compensation had a pooled increased risk of revision surgery by 133% (odds ratio, 2.33 [95% CI, 2.09-2.60]). Age, smoking status, diabetes, and obesity were found to be risk factors in half of the analyzed studies., Conclusion: Corticosteroid injections, regardless of the frequency of injections, and workers' compensation status were found to be significant risk factors across the literature based on qualitative analysis and pooled analysis. Surgeons should determine ideal candidates for arthroscopic RCR by accounting for corticosteroid injection history, regardless of the frequency, and insurance status of the patient., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.H. has received personal fees from DJO/Enovis, Moximed, and Vericel; support for education from Smith & Nephew and Medwest Associates; and hospitality payments from Medical Device Business Services. G.E.G. has received consulting fees from Encore Medical, DePuy Synthes, Medical Device Business Services, Wright Medical Technology, Bioventus, and AzurMeds; royalties from Stryker, Encore Medical, and Wright Medical Technology; personal fees from Additive Orthopaedics, Mitek, and Tornier; and grants from Arthrex and SouthTech; he holds stock in cultivate(MD), Genesys, PatientIQ, ROM3, and Stryker. N.V. has received consulting fees and royalties from Arthrex; grants from Breg, Ossur, Smith & Nephew, and Wright Medical Technology; royalties from Smith & Nephew and Vindico Medical Education; and personal fees from Stryker. A.Y. has received consulting fees from AlloSource, CONMED Linvatec, JRF Ortho, and Olympus; is an unpaid consultant for PatientIQ, Smith & Nephew, and Sparta Biomedical; has received research support from Vericel, Arthrex, and Organogenesis; and hospitality payments from Stryker; and holds stock or stock options in PatientIQ. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Total disc replacement (TDR) is widely used in the treatment of cervical and lumbar spine pathologies. Although TDR infection, particularly delayed infection, is uncommon, the results can be devastating, and consensus on clinical management remains elusive. In this review of the literature, we asked: (1) What are the reported rates of TDR infection; (2) What are the clinical characteristics of TDR infection; and (3) How has infection been managed for TDR patients?, Methods: We performed a search of the literature using PubMed and Embase to identify studies that reported TDR infection rates, the identification and management of TDR infection, or TDR failures with positive cultures. Twenty database studies (17 focusing on the cervical spine and 3 on the lumbar spine) and 10 case reports representing 15 patients were reviewed along with device Summary of Safety and Effectiveness Data reports., Results: We found a lack of clarity regarding how infection was diagnosed, indicating a variation in clinical approach and highlighting the need for a standard definition of TDR infection. Furthermore, while reported infection rates were low, the absence of a clear definition prevented robust data analysis and may contribute to underreporting in the literature. We found that treatment strategy and success rely on several factors including patient symptoms and time to onset, microorganism type, and implant positioning/stability., Conclusions: Although treatment strategies varied throughout the extant literature, common practices in eliminating infection and reconstructing the spine emerged. The results will inform future work on the creation of a more robust definition of TDR infection and as well as recommendations for management., Competing Interests: None., (© 2024 The Author(s).)

Purpose of Review: Irreparable subscapularis tears, especially in younger patients with higher functional demands, present a challenging entity. Pectoralis major and latissimus dorsi tendon transfers are commonly considered for surgical management of this pathology, yet no consensus exists regarding the superior option. The purpose of this article is to review the most current tendon transfer techniques for irreparable subscapularis tears., Recent Findings: For decades, transfer of the pectoralis major has been considered the gold standard technique for irreparable subscapularis tears. This transfer was found to reduce pain and improve functional outcome scores, yet range of motion and force of internal rotation were not maintained in long-term follow-up studies. The latissimus dorsi tendon transfer for the same indications has demonstrated biomechanical superiority in recent cadaveric studies with promising short-term results clinically. Both pectoralis major and latissimus dorsi tendon transfers improve outcomes of patients with irreparable subscapularis tears. Future comparative studies are still needed to determine superiority amongst techniques., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques., Methods: Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified., Results: A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009)., Conclusion: Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification., (© 2024 The Authors.)

Background: Traditional, commercially sourced patient-specific instrumentation (PSI) systems for shoulder arthroplasty improve glenoid component placement but can involve considerable cost and outsourcing delays. The purpose of this randomized controlled trial was to compare the accuracy of glenoid component positioning in anatomic total shoulder arthroplasty (aTSA) using an in-house, point-of-care, 3-dimensionally (3D) printed patient-specific glenoid drill guide vs. standard nonspecific instrumentation., Methods: This single-center randomized controlled trial included 36 adult patients undergoing primary aTSA. Patients were blinded and randomized 1:1 to either the PSI or the standard aTSA guide groups. The primary endpoint was the accuracy of glenoid component placement (version and inclination), which was determined using a metal-suppression computed tomography scan taken between 6 weeks and 1 year postoperatively. Deviation from the preoperative 3D templating plan was calculated for each patient. Blinded postoperative computed tomography measurements were performed by a fellowship-trained shoulder surgeon and a musculoskeletal radiologist., Results: Nineteen patients were randomized to the patient-specific glenoid drill guide group, and 17 patients were allocated to the standard instrumentation control group. There were no significant differences between the 2 groups for native version (P = .527) or inclination (P = .415). The version correction was similar between the 2 groups (P = .551), and the PSI group was significantly more accurate when correcting version than the control group (P = .042). The PSI group required a significantly greater inclination correction than the control group (P = .002); however, the 2 groups still had similar accuracy when correcting inclination (P = .851). For the PSI group, there was no correlation between the accuracy of component placement and native version, native inclination, or the Walch classification of glenoid wear (P > .05). For the control group, accuracy when correcting version was inversely correlated with native version (P = .033), but accuracy was not correlated with native inclination or the Walch classification of glenoid wear (P > .05). The intraclass correlation coefficient was 0.703 and 0.848 when measuring version and inclination accuracy, respectively., Conclusion: When compared with standard instrumentation, the use of in-house, 3D printed, patient-specific glenoid drill guides during aTSA led to more accurate glenoid component version correction and similarly accurate inclination correction. Additional research should examine the influence of proper component position and use of PSI on clinical outcomes., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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 (r pb  = -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., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: In the rehabilitation of injured baseball pitchers, there is lack of consensus on how to guide a player back to pitching. It is unknown how different contemporary interval throwing programs (ITPs) progress in the amount of throwing workload., Purposes: To 1) evaluate three prominent ITPs commonly employed in baseball pitcher rehabilitation and assess whether these ITPs produce training loads that increase in a controlled, graduated manner and 2) devise an ITP that produced training loads which increased steadily over time., Study Design: Cross-sectional study., Methods: Three publicly available ITPs from prominent sports medicine institutions were analyzed. Elbow varus torque per throw was calculated from a 2 nd order polynomial regression based upon a relationship between recorded torque measurements and throwing distance measured from a database of 111,196 throws. The relative rate of workload increase was measured as an acute:chronic workload ratio (ACWR). For each ITP, throw counts, daily/acute/chronic workloads, and ACWR were calculated and plotted over time. Finally, an original ITP was devised based upon a computational model that gradually increases ACWR over time and finished with an optimal chronic workload., Results: Each ITP exhibited a unique progression of throwing distances, quantities, and days to create different workload profiles. The three ITPs had throwing schedules ranging from 136 days to 187 days, ACWR spiked above or fell below a literature-defined "safe" range (i.e. 0.7 - 1.3) 19, 21, and 23 times. A novel ITP, predicated on a 146-day schedule and with a final chronic workload of 14.2, was designed to have no spikes outside of the safe range., Conclusion: Existing ITPs widely utilized for rehabilitation of baseball pitchers exhibit significantly inconsistent variation in the rate of throwing load progression. Computational modeling may facilitate more incremental workload progression in ITPs, thereby reducing injury during rehabilitation and more efficiently condition a pitcher for return to competition., Level of Evidence: 3b., (© The Author(s).)

Background: Latissimus dorsi transfer is a surgical procedure that can be used for treating posterosuperior rotator cuff tears. The procedure leads to improved shoulder function via alterations in the force vector couple around the shoulder. However, there is still no consensus on the biomechanical changes resulting from latissimus dorsi transfer., Methods: We performed a systematic review of the literature on 3D motion analysis studies evaluating the effects of latissimus dorsi transfer on shoulder kinematics. The available data on segment and joint range of motion was extracted and subject to meta-analysis when consistent across the studies., Findings: Our meta-analysis of pre- and post-operative studies revealed a significant improvement in forward flexion and abduction following latissimus dorsi transfer. When comparing the latissimus transferred shoulder with an uninjured contralateral side the meta-analysis found no significant difference in flexion range of motion, while abduction and external rotation was significantly higher in the uninjured shoulders. The overall risk of bias was moderate to high. High heterogeneity was found in the reporting of data, which limited our ability to perform a meta-analysis across the studies for all interest outcomes., Interpretations: Our findings suggest that latissimus dorsi transfer for posterosuperior rotator cuff tears effectively improves shoulder flexion and abduction. External rotation is also expected to improve but at inferior levels as compared to the unaffected side. However, the heterogeneity of the reported data on 3D motion analysis studies highlights the need for better standardization in research and reporting as to conclude the impact of different joints., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants., Methods: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA., Results: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001)., Conclusion: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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.

Background: Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management., Methods: Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the "People also ask" section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria., Results: The most frequent UCL tear questions were "how long does it take to heal a torn UCL?" and "what is nonsurgical treatment for the UCL?" The most frequent UCL surgery question was "can you retear your UCL after surgery?" The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information., Conclusion: Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency., (© 2023 The Authors.)

Background: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status., Methods: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis., Results: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort., Conclusion: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Currently, most pitching instructors suggest a shorter arm path-the total distance the arm travels during pitching. Theoretically, this combination allows for better body segment sequencing, a more efficient energy transfer through the kinetic chain, and increased ball velocity, while limiting elbow varus torque., Hypothesis: Shorter arm paths would be associated with increased ball velocity and decreased elbow varus torque., Study Design: Descriptive laboratory study., Methods: A total of 182 professional pitchers threw 8 to 12 fastball pitches while evaluated by 3-dimensional motion capture (480 Hz). The arm path was calculated as the total distance the hand marker traveled during the pitch. The pitch was divided into early, late, and total arm paths. A linear regression model assessed the interpitcher relationship between arm path, elbow varus torque, and ball velocity. A linear mixed-effects model with random intercepts assessed intrapitcher relationships., Results: Interpitcher comparison showed that total arm path weakly correlated with greater elbow varus torque ( P = .025). Strong correlations were found between ball velocity and early ( R 2 = 0.788; P < .001), late ( R 2 = 0.787; P = .024), and total arm paths ( R 2 = 0.792; P < .001). Strong positive intrapitcher correlations were found between elbow varus torque and early ( R 2 = 0.962; P < .001) and total arm path ( R 2 = 0.964; P < .001). For individual pitchers, there was a large variation in the early (30.1 ± 15.7 cm) and late (21.4 ± 12.1 cm) arm path. For every 30-cm (11.8-inch) increase in early arm path (the mean range for an individual pitcher), there was a 1.29-N (β = 0.0429) increase in elbow varus torque and a 0.354 m/s (0.79 mph) (β = 0.0118) increase in ball velocity., Conclusion: A shorter arm path correlated with decreased elbow varus torque and decreased ball velocity in intrapitcher comparisons. Determining the individual mechanics that decrease elbow varus torque may help coaches and trainers correct these patterns., Clinical Significance: A shorter arm path during the pitch can decrease elbow varus torque, which limits the load on the medial elbow but also has a detrimental effect on ball velocity. An improved understanding of the impact of shortening arm paths on stresses on the throwing arm may help minimize injury risk., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.R.C. has received hospitality payments from Encore Medical and Medical Device Business Services, and education payments from Medwest Associates. G.P.N. has received royalties from Anika Therapeutics, Stryker, Arthrosurface, and Wright Medical; consulting fees from Anika Therapeutics, AzurMeds, KCI USA, Stryker, Arthrosurface, and Wright Medical; nonconsulting fees from Arthrosurface and Wright Medical; and honoraria from Arthrosurface. N.N.V. has received consulting fees from Arthrex, Smith & Nephew, and Stryker; nonconsulting fees from Arthrex; royalties from Arthrex, Smith & Nephew, and Graymont Professional Products; and hospitality payments from Relievant Medsystems. G.E.G. has received consulting fees from AzurMeds, DePuy/Medical Device Business Services, Encore Medical, Wright Medical, and Bioventus; royalties from Encore Medical, Stryker, and Wright Medical; and honoraria from Wright Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Excellent short-term outcomes after reverse shoulder arthroplasty (RSA) have been reported, but longer term outcomes in the existing literature are sparse and vary widely. The purpose of this study is to systematically assess the existing literature to quantify functional outcomes and complication rates after RSA at a minimum of five years of follow-up., Methods: A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant systematic literature search of the PubMed and Embase databases was undertaken. Studies reporting outcomes after primary RSA for nontrauma-related indications with a minimum of 5-year follow-up were included., Results: Overall, 20 studies satisfied all inclusion criteria. This represented 1591 shoulders in 1556 patients (32.1% males), with a mean age of 70.2 ± 5.0 years and mean follow-up of 8.8 years, or 106.2 ± 30.1 months (60-243). At final follow-up, the mean reported Constant Murley score was 62.1 ± 5.0 (49.0-83.0). The mean adjusted Constant Murley score was 83.5 ± 12.5 (58-111.9). The mean American Shoulder and Elbow Surgeons score was 81.8 ± 4.6, while the mean subjective shoulder value was 74.6 ± 6.4. Overall, 88% of patients rated their satisfaction as either good or very good. The range of active forward flexion, abduction, external, and internal rotation were respectively, 126° ± 13°, 106° ± 11°, 22° ± 11°, and 6° ± 2°. The overall rate of revision surgery was 4.9% (0%-45.5%). Regarding complications, the rate of prosthetic joint infection was 4.3% (0%-26.7%), shoulder dislocation was 3.7% (0%-20.4%), and acromial fracture was 2.0% (0%-8.8%). At final follow-up, 30.9% of shoulders had some degree of scapular notching., Conclusion: This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up., (© 2023 The Author(s).)

Background: Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs., Methods: Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests., Results: Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs., Conclusion: Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality., Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys., Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey ( P  = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% ( P  = .8)., Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management., Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

Background: Pseudoparalysis is commonly used to describe patients with severe loss of active elevation associated with advanced rotator cuff disease, but its definition in the literature has been variable. This study aimed to determine how 15 expert shoulder surgeons use the term "pseudoparalysis" when presented with clinical cases and assess clinical agreement on the diagnosis of pseudoparalysis., Methods: Fifteen expert shoulder surgeons were surveyed regarding 18 patients with magnetic resonance imaging-diagnosed massive rotator cuff tears, restricted active range of motion (ROM), full passive ROM, and without advanced rotator cuff arthropathy (Hamada grade <3). The survey included 18 patient vignettes with key clinical details and a deidentified video demonstrating the physical examination of the patient. For all patients, surgeons were instructed to assume that the patient has a full passive ROM. An anteroposterior radiograph and T2 sequences of the patient's coronal, axial, and sagittal magnetic resonance imaging were also provided. After each case, the surgeons were asked: (1) does the patient have pseudoparalysis, and (2) if so, how severe it is. At the end of the patient vignettes, surgeons were asked to define pseudoparalysis using a checklist with predefined options. Surgeons were also asked if there was a difference between the term pseudoparalysis and pseudoparesis. Fleiss' kappa (κ) correlation coefficient was used to determine intersurgeon agreement., Results: There was minimal inter-rater agreement on the diagnosis of pseudoparalysis (κ = 0.360) and no agreement on describing the severity of pseudoparalysis (κ = -0.057). Although 80% of surgeons stated that an active glenohumeral elevation less than 90° was a diagnostic feature of pseudoparalysis, there was disagreement on the remaining criteria, leading to no agreement on a set of universal criteria that defines pseudoparalysis. A total of 67% included maintained full passive elevation, 33% included the absence of pain, 67% included elevation causing anterosuperior escape, and 27% included an additional unlisted factor. There was minimal agreement among the 15 surgeons on the diagnostic criteria of pseudoparalysis (κ = 0.092). Finally, 7 surgeons stated that pseudoparalysis and pseudoparesis are identical, whereas 8 surgeons stated that they are 2 different clinical diagnoses., Conclusion: Among this panel of expert shoulder surgeons, there was a lack of consensus on the definition of pseudoparalysis and minimal agreement on the diagnosis of pseudoparalysis based on clinical scenarios. In addition, half the surgeons believed that pseudoparalysis and pseudoparesis are identical, whereas the other half believed that they represent 2 separate clinical entities. A standardized definition of pseudoparalysis would be of value to facilitate communication and research efforts., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform a preclinical histologic assessment of a biphasic acellular interpositional cancellous allograft in an ovine model of rotator cuff repair (RCR) designed to better understand its safety profile and effects on tendon healing after RCR., Methods: Thirty skeletally mature sheep with clinically normal shoulders with an artificially created degenerative infraspinatus tendon tear were randomized to control and treatment groups. Animals were euthanized at 3 weeks, 6 weeks, and 12 weeks. After gross dissection, rotator cuff specimens were fixed with formalin and polymerized for sectioning and staining. Blinded histologic scores evaluated inflammatory cell infiltrates, signs of degradation, particulate debris, collagen arrangement, neovascularization, and enthesis qualitative measures., Results: There were no treatment specimens that exhibited histologic signs of a significant infection, inflammatory infiltrate, or foreign body reaction such as granuloma or fibrous capsule formation. Histologic scores in all categories were not significantly different at all time points, including the primary end point mean cumulative inflammatory score (control: 3.66 ± 1.21 vs treated: 4.33 ± 1.51, P = .42), when comparing the treatment and control RCR groups. In general, the degree of tendon healing and host tissue response was essentially equivalent between the 2 groups with observation of low overall levels of inflammation and progressive improvements in collagen organization, reduced tenocyte activity, and fibrocartilaginous enthesis reformation., Conclusions: This histologic study demonstrated the use of a biphasic interpositional allograft for RCR augmentation in an ovine model does not generate an inflammatory response or foreign body reaction. Use of the biphasic interpositional allograft resulted in a histological profile that was essentially equivalent to that of a standard RCR at 3-, 6-, and 12-week postoperative timepoints. These findings suggest that a biphasic interpositional allograft is safe for further clinical investigation in humans before broader clinical application., Clinical Relevance: Patch augmentation of RCR is a popular technique that has shown clinical success in improving the likelihood of a successful repair in patients at elevated risk for retear. Newer augmentation technologies are being developed to address the biology at the interface between the bone and soft tissue where failure typically occurs., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: All-suture anchors and knotless anchors are increasingly used in the repair of anteroinferior labral tears in patients with shoulder instability. Optimal repair constructs may limit recurrent instability., Purpose: To perform a quantitative biomechanical comparison of 3 labral fixation devices for soft tissue Bankart lesions: knotless soft-body tensionable anchor (SB knotless), knotted soft-body anchor (SB knotted), and knotless hard-body PEEK (polyether ether ketone) interference anchor (HB knotless)., Study Design: Controlled laboratory study., Methods: A total of 21 glenoid specimens were randomized into 3 groups: SB knotless, SB knotted, and HB knotless. Artificial Bankart lesions were created at the anteroinferior labrum. Anchors were placed at the 3:30, 4:30, and 5:30 clockface positions, and sutures were passed through 1 cm of tissue. Anchors were tested simultaneously as one construct by pulling capsular tissue connected to the anteroinferior quadrant. Cyclic loading (5-25 N, 100 cycles) was followed by load-to-failure testing (15 mm/min). Biomechanical testing variables were collected, and failure mechanisms were recorded per individual anchor., Results: There were no differences in baseline specimen characteristics. There was no difference in elongation during cyclic loading ( P = .40). The ultimate load to failure between SB knotless (309.7 ± 125.6 N), SB knotted (226.4 ± 34.8 N), and HB knotless (256.5 ± 90.5 N) did not significantly differ ( P = .25). Failure mechanisms differed among groups ( P = .008); mechanisms included anchor pullout (SB knotless: 33.3%; SB knotted: 23.8%; HB knotless: 28.6%), suture pull-through (SB knotless: 66.7%; SB knotted: 38.1%; HB knotless: 33.3%), and anchor fixation method failure, defined as knot failure for knotted anchors or locking mechanism failure for knotless anchors (SB knotless: 0.0%; SB knotted: 38.1%; HB knotless: 38.1%).)., Conclusion: The SB knotless, SB knotted, and HB knotless labral fixation anchors studied exhibited comparable elongation during cyclic loading, stiffness, and ultimate loads to failure in a cadaveric model. However, the failure mechanisms significantly differed, as SB knotless anchors failed primarily from suture pull-through, while SB knotted and HB knotless anchors were subject to knot failure and locking mechanism failure, respectively., Clinical Relevance: These data support the benefit of SB knotless anchors for anteroinferior labral repair in limiting knot failure typically seen with knotted anchors, perhaps demonstrating that all-suture anchors may have better locking mechanism quality than their PEEK counterparts.

Background: The goals of this study were to optimize superior capsular reconstruction by assessing the relative fixation strength of 4 suture anchors; evaluating 3 glenoid neck locations for fixation strength and bone mineral density (BMD); determining if there is a correlation between BMD and fixation strength; and determining which portal sites have optimal access to the posterosuperior and anterosuperior glenoid neck for anchor placement., Methods: Twenty cadaveric specimens were randomized into 4 groups: all-suture anchor (FiberTak), conventional 3.0-mm knotless suture anchor (SutureTak), 3.9-mm knotless PEEK (polyetheretherketone) Corkscrew anchor, and 4.5-mm Bio-Corkscrew anchor. Each specimen was prepared with 3 anchors into the glenoid: an anterosuperior anchor, superior anchor, and posterosuperior anchor. All anchors were inserted into the superior glenoid neck 5 mm from the glenoid rim. A materials testing system performed cyclic testing (250 cycles) followed by load-to-failure testing at 12.5 mm/s. Cyclic elongation, first cycle excursion, maximum load, and stiffness were recorded. Using custom software, BMD was calculated at each anchor location. This software was also used to assess access to the posterosuperior and anterosuperior glenoid neck from standard arthroscopic portal positions., Results: There was no significant difference in cyclic elongation ( P  = .546), first cycle excursion ( P  = .476), maximum load ( P  = .817), or stiffness ( P  = .309) among glenoid anchor positions. Cyclic elongation was significantly longer in the PEEK Corkscrew group relative to the other implants ( P  ≤ .002). First cycle excursion was significantly greater in the FiberTak group relative to all other implants ( P  ≤ .008). For load-to-failure testing, the Bio-Corkscrew group achieved the highest maximum load ( P  ≤ .001). No other differences in cyclic or failure testing were observed between the groups. No differences in stiffness testing were observed ( P  = .133). The superior glenoid rim had the greatest BMD ( P  = .003), but there was no correlation between BMD and cyclic/load outcomes. The posterior portal (80% of specimens) and the anterior portal (60% of specimens) demonstrated the best access to the posterosuperior and anterosuperior glenoid neck, respectively., Conclusion: The 4.5-mm Bio-Corkscrew anchor provided the most robust fixation to the glenoid during superior capsular reconstruction as it demonstrated the strongest maximum load, had minimal elongation, had minimal first cycle excursion, and did not fail during cyclic testing. The superior glenoid neck had the highest BMD; however, there was no correlation between BMD or glenoid anchor location and biomechanical outcomes. The posterior portal and anterior portal provided optimal access to the posterosuperior glenoid neck and anterosuperior glenoid neck, respectively., (© 2023 Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.)

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., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Recent work has shown inpatient length of stay (LOS) following shoulder arthroplasty to hold the second strongest association with overall cost (after implant cost itself). In particular, a preoperative understanding for the patients at risk of extended inpatient stays (≥3 days) can allow for counseling, optimization, and anticipating postoperative adverse events., Methods: A multicenter retrospective review was performed of 5410 anatomic (52%) and reverse (48%) total shoulder arthroplasties done at 2 large, tertiary referral health systems. The primary outcome was extended inpatient LOS of at least 3 days, and over 40 preoperative sociodemographic and comorbidity factors were tested for their predictive ability in a multivariable logistic regression model based on the patient cohort from institution 1 (derivation, N = 1773). External validation was performed using the patient cohort from institution 2 (validation, N = 3637), including area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values., Results: A total of 814 patients, including 318 patients (18%) in the derivation cohort and 496 patients (14%) in the validation cohort, experienced an extended inpatient LOS of at least 3 days. Four hundred forty-five (55%) were discharged to a skilled nursing or rehabilitation facility. Following parameter selection, a multivariable logistic regression model based on the derivation cohort (institution 1) demonstrated excellent preliminary accuracy (AUC: 0.826), with minimal decrease in accuracy under external validation when tested against the patients from institution 2 (AUC: 0.816). The predictive model was composed of only preoperative factors, in descending predictive importance as follows: age, marital status, fracture case, ASA (American Society of Anesthesiologists) score, paralysis, electrolyte disorder, body mass index, gender, neurologic disease, coagulation deficiency, diabetes, chronic pulmonary disease, peripheral vascular disease, alcohol dependence, psychoses, smoking status, and revision case., Conclusion: A freely-available, preoperative online clinical decision tool for extended inpatient LOS (≥ 3 days) after shoulder arthroplasty reaches excellent predictive accuracy under external validation. As a result, this tool merits consideration for clinical implementation, as many risk factors are potentially modifiable as part of a preoperative optimization strategy., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Clinically significant outcome (CSO) thresholds for the Patient-Reported Outcome Measurement Information System-Upper Extremity (PROMIS-UE) score have been previously defined after arthroscopic rotator cuff repair (RCR). However, the time required to achieve CSOs for the PROMIS-UE score is unknown., Purpose: To (1) determine the time required to achieve the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) score thresholds after RCR for the PROMIS-UE questionnaire and (2) identify patient factors associated with earlier or delayed achievement of these clinical benchmarks., Study Design: Case-control study; Level of evidence, 3., Methods: A prospectively maintained institutional database was retrospectively reviewed for consecutive patients who underwent RCR between January 2018 and January 2019. Patients were included if they completed the PROMIS-UE questionnaire both preoperatively and at standardized postoperative time intervals: 5 to 7 months (6-month time point), 11 to 13 months (1-year time point), and ≥23 months (2-year time point). Kaplan-Meier survival curves with interval censoring were used to define the cumulative percentage of patients who achieved the MCID, SCB, and PASS. Patient variables associated with earlier or delayed achievement of the MCID, SCB, and PASS were determined using Weibull parametric survival regression analysis., Results: Included were 105 patients undergoing RCR (age, 57.3 ± 10.3 years; body mass index, 31.5 ± 6.1 kg/m 2 ). By 2-year follow-up, the cumulative percentage of patients achieving the MCID, SCB, and PASS was 86.7%, 76.2%, and 74.3%, respectively. The mean time required to reach the MCID, SCB, and PASS score thresholds was 9.5 ± 3.8, 10.3 ± 4.4, and 9.8 ± 4.6 months, respectively. Factors associated with delayed achievement of CSOs included greater baseline PROMIS-UE score (MCID and SCB) and workers' compensation insurance (PASS). Greater baseline PROMIS-UE scores were associated with earlier achievement of the PASS., Conclusion: Most patients achieved CSOs for the PROMIS-UE within 12 months of RCR. Patient-specific factors found to be associated with earlier or delayed achievement of CSOs can be used to inform patient discussions on the expected timeline for recovery after RCR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.C.F. has received grant support from Acumed and Arthrex; education payments from Medwest, Smith & Nephew, and Zimmer; consulting fees from Encore Medical; and hospitality payments from Stryker. G.E.G. has received consulting fees from AzurMeds, Bioventus, DePuy, Encore Medical, Stryker, and Wright Medical; nonconsulting fees from Wright Medical; royalties from Encore Medical, Stryker, and Wright Medical; honoraria from Wright Medical; and hospitality payments from Arthrex and Smith & Nephew. A.B.Y. has received education payments from Medwest, consulting fees from JRF Ortho and Olympus America; nonconsulting fees from Arthrex; honoraria from JRF Ortho; and hospitality payments from Stryker. B.F. has received education payments from Medwest and consulting fees from Stryker. B.J.C. has received education payments from Endo Pharmaceuticals; consulting fees from Acumed, Aesculap Biologics, Anika Therapeutics, Bioventus, Endo Pharmaceuticals, Flexion Therapeutics, Geistlich Pharma North America, Ossic, Ossio, Pacira Pharmaceuticals, Smith & Nephew, and Vericel; nonconsulting fees from Aesculap Biologics, Arthrex, LifeNet Health, Pacira Pharmaceuticals, and Terumo BCT; royalties from Arthrex; honoraria from Vericel; and hospitality payments from GE Healthcare. N.N.V. has received education payments from Medwest; consulting fees from Arthrex, Medacta, Smith & Nephew, and Stryker; nonconsulting fees from Arthrex and Smith & Nephew; royalties from Arthrex, Smith & Nephew, and Graymont Professional Products; and hospitality payments from Relievant Medsystems. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: This study analyzed questions searched by rotator cuff patients and determined types and quality of websites providing information., Methods: Three strings related to rotator cuff repair were explored by Google Search. Result pages were collected under the "People also ask" function for frequent questions and associated webpages. Questions were categorized using Rothwell classification and topical subcategorization. Webpages were evaluated by Journal of the American Medical Association (JAMA) benchmark criteria for source quality., Results: One hundred twenty "People also ask" questions were collected with associated webpages. Using the Rothwell classification of questions, queries were organized into fact (41.7%), value (31.7%), and policy (26.7%). The most common webpage categories were academic (28.3%) and medical practice (27.5%). The most common question subcategories were timeline of recovery (21.7%), indications/ management (21.7%), and pain (18.3%). Average JAMA score for all 120 webpages was 1.50. Journal articles had the highest average JAMA score (3.77), while commercial websites had the lowest JAMA score (0.91). The most commonly suggested question for rotator cuff repair/ surgery was, "Is rotator cuff surgery worth having?," while the most commonly suggested question for rotator cuff repair pain was, "What happens if a rotator cuff is not repaired?", Conclusions: The most commonly asked questions pertaining to rotator cuff repair evaluate management options and relate to timeline of recovery and pain management. Most information is provided by medical practice, academic, and medical information websites, which have highly variable reliability. By understanding questions their patients search online, surgeons can tailor preoperative education to patient concerns and improve postoperative outcomes.

Background: Common questions about shoulder arthroplasty (SA) searched online by patients and the quality of this content are unknown. The purpose of this study is to uncover questions SA patients search online and determine types and quality of webpages encountered., Methods: The "People also ask" section of Google Search was queried to return 900 questions and associated webpages for general, anatomic, and reverse SA. Questions and webpages were categorized using the Rothwell classification of questions and assessed for quality using the Journal of the American Medical Association (JAMA) benchmark criteria., Results: According to Rothwell classification, the composition of questions was fact (54.0%), value (24.7%), and policy (21.3%). The most common webpage categories were medical practice (24.6%), academic (23.2%), and medical information sites (14.4%). Journal articles represented 8.9% of results. The average JAMA score for all webpages was 1.69. Journals had the highest average JAMA score (3.91), while medical practice sites had the lowest (0.89). The most common question was, "How long does it take to recover from shoulder replacement?", Conclusions: The most common questions SA patients ask online involve specific postoperative activities and the timeline of recovery. Most information is from low-quality, non-peer-reviewed websites, highlighting the need for improvement in online resources. By understanding the questions patients are asking online, surgeons can tailor preoperative education to common patient concerns and improve postoperative outcomes.

Osteoarthritic shoulders with posterior glenoid erosion present a unique challenge to shoulder arthroplasty surgeons. Although numerous treatment options and techniques have been described, a consensus regarding the optimal surgical management strategy has not been reached. It is important to summarize the best available evidence regarding these different treatment options, with a particular focus on the young patient.

Background: Early pelvic rotation has been associated with decreased throwing arm kinetics in college baseball pitchers, though professional pitchers have yet to be examined., Purpose: To investigate the effect of pelvic rotation on trunk, pelvis and lower extremity kinematics, as well as throwing arm kinetics and pitch velocity in professional baseball pitchers., Study Design: Descriptive laboratory study., Methods: Data were analyzed for 157 professional baseball pitchers throwing fastballs using 3-dimensional motion capture (480 Hz). Pitchers were divided into an open pelvis (rotated toward target; n = 78) and a closed pelvis (n = 79) group based on pelvic rotation at foot contact. Variables of interest were compared between the groups using t tests and 2-way analysis of variance, while Spearman correlation was used to measure relationships between the variables of interest., Results: Pitchers in the open group had a longer stride length (81% ± 5% vs 77% ± 5% body height; P < .01, d = 0.74), greater lead knee flexion (49° ± 6° vs 47° ± 10°; P = .043, d = 0.33), faster peak knee extension velocity (424°/s ± 158°/s vs 325°/s ± 142 °/s; P < .01, d = 0.66), and faster ball velocity (39.1 ± 1.7 m/s vs 38.4 ± 2.1 m/s; P = .029, d = 0.35) compared with those in the closed group. There was no significant difference in elbow varus torque between the 2 groups (open: 87.8 ± 14.7 N·m, closed: 90.5 ± 17.2 N·m; P = .311). There were moderate negative relationships between pelvic rotation at foot contact and stride length ( r S = -0.385, P < .001), lead knee extension ( r S = -0.429, P < .001), and peak lead knee extension velocity ( r S = -0.359, P < .001)., Conclusion: Professional pitchers who landed with an open pelvis demonstrated longer stride length, greater lead knee extension, faster lead knee velocity, and faster ball velocity compared with pitchers with a closed pelvis at foot contact. This increase in segment velocities and ball velocity was not associated with an increase in elbow varus torque and displays a potentially efficient method in which pitchers can increase ball velocity without an increase in elbow varus torque., Clinical Relevance: Instructing pitchers to rotate their pelvis toward the target at foot contact may allow pitchers to transfer momentum up the kinetic chain more efficiently, while producing greater ball velocity and limiting the torque sustained at the elbow., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.M.K. has received grant support from Arthrex and education payments from Medwest and Smith & Nephew. G.E.G. has received consulting fees from Bioventus, Encore Medical, Medical Device Business Services, and Wright Medical; speaking fees from Wright Medical; royalties from Encore Medical, Stryker, and Wright Medical; and hospitality payments from Arthrex and Smith & Nephew. G.P.N. has received nonconsulting fees from Arthrosurface and Wright Medical, honoraria from Arthrosurface, and royalties from Arthrosurface and Wright Medical. N.N.V. has received education payments from Medwest; consulting fees from Arthrex, Medacta, Smith & Nephew, and Stryker; speaking fees from Arthrex; royalties from Graymont Professional Products and Smith & Nephew; and hospitality payments from Relievant Medsystems. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging., Purpose: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score., Results: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis., Conclusion: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

Background: Total shoulder arthroplasty (TSA) has become the gold-standard treatment to relieve joint pain and disability in patients with glenohumeral osteoarthritis who do not respond to conservative treatment. An adverse reaction to metal debris released due to fretting corrosion has been a major concern in total hip arthroplasty. To date, it is unclear how frequently implant corrosion occurs in TSA and whether it is a cause of implant failure. This study aimed to characterize and quantify corrosion and fretting damage in a single anatomic TSA design and to compare the outcomes to the established outcomes of total hip arthroplasty., Methods: We analyzed 21 surgically retrieved anatomic TSAs of the same design (Tornier Aequalis Pressfit). The retrieved components were microscopically examined for taper corrosion, and taper damage was scored. Head and stem taper damage was quantitatively measured with a non-contact optical coordinate-measuring machine. In selected cases, damage was further characterized at high magnifications using scanning electron microscopy. Energy-dispersive x-ray spectroscopy and metallographic evaluations were performed to determine underlying alloy microstructure and composition. Comparisons between groups with different damage features were performed with independent-samples t tests; Mann-Whitney tests and multivariate linear regression were conducted to correlate damage with patient factors. The level of statistical significance was set at P < .05., Results: The average material loss for head and stem tapers was 0.007 mm 3 and 0.001 mm 3 , respectively. Material loss was not correlated with sex, age, previous implant, or time in situ (P > .05). We observed greater volume loss in head tapers compared with stem tapers (P = .002). Implants with evidence of column damage had larger volumetric material loss than those without such evidence (P = .003). Column damage aligned with segregation bands within the alloy (preferential corrosion sites). The average angular mismatch was 0.03° (standard deviation, 0.0668°), with negative values indicating distal engagement and positive values indicating proximal engagement. Implants with proximal engagement were significantly more likely to have column damage than those with distal engagement (P = .030)., Discussion: This study has shown not only that the metal components of TSA implants can corrode but also that the risk of corrosion can be reduced by (1) eliminating preferential corrosion sites and (2) ensuring distal engagement to prevent fluid infiltration into the modular junction., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)