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Background: Orthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty. Methods: A retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences. Results: Preoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P

Background Opioid analgesics play an essential role in postoperative pain management; however, they are also associated with high rates of abuse and decreased patient outcomes. With the declaration of the recent opioid crisis, more scrutiny has been placed on physicians and their prescribing habits, and orthopedic surgeons have been shown to be the third-largest providers of opioids. Many patients undergoing reverse shoulder arthroplasty (RSA) have acute and chronic pain and may be prescribed opioids. The purpose of this study was to understand opioid-prescribing patterns across all specialties for patients undergoing RSA. Methods A retrospective review of preoperative and postoperative opioid use in 407 patients who underwent RSA from 2012 to 2015 was performed. Demographic data including age, sex, race, ethnicity, body mass index, American Society of Anesthesiologists class, and smoking status were recorded. Opioid prescriptions within 90 days before and after surgery were collected using state-mandated prescription drug–monitoring databases. Prescriber specialty was recorded, and prescriptions were categorized as follows: orthopedic surgery, primary care or internal medicine, pain management and anesthesia, dentistry, and emergency medicine. Results The cohort was composed of 236 women (58.0%) and 171 men (42.0%). The average age was 71 years. Forty-six percent of patients received preoperative prescriptions, of which 24.7% were written by orthopedic surgeons and 60.0% were written by internal medicine specialists. Preoperatively, 20% of patients received >3 prescriptions for opioids, and postoperatively, 36.4% of patients received >3 opioid prescriptions. Fifty-nine percent of all postoperative prescriptions were written by orthopedists, and 35.2% were written by internal medicine specialists. Conclusion Not surprisingly, orthopedic surgeons prescribed the majority of postoperative prescriptions. Increased awareness, however, of preoperative prescribing habits by other specialty providers may be needed, with communication of their prescriptions to orthopedists, as preoperative use is the strongest predictor of postoperative dependence on opioids. Physicians should be aware of the number of patients receiving multiple prescriptions and their contribution to dependence with continued refills postoperatively. Therefore, surgeons must be more meticulous in assessing opioid consumption before surgery, as well as which providers are writing prescriptions after surgery, to limit opioid dispensation.

Histoplasma capsulatum periprosthetic knee infection has rarely been reported in the literature due to its low frequency. Notwithstanding, it is important to keep it among the differential diagnoses to avoid delays in treatment. The current report presents the case of infectious knee monoarthritis in an immunocompetent patient after unicompartmental knee arthroplasty. The joint infection was accompanied by disseminated histoplasmosis, which initiated an autoimmune reaction, ensuing a systemic inflammatory response syndrome. The management protocol used in this case was successful and included staged arthroplasty reconstruction combined with chronic antifungal and steroid pharmacotherapy. Approximately 4 years after total knee arthroplasty revision, there were no clinical signs of localized or systemic infection. Keywords: Periprosthetic joint infection, Histoplasmosis, Total knee arthroplasty, Systemic inflammatory response syndrome, SIRS

Hypothesis and background Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores. Methods We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores. Results A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs. Conclusion In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.

Background: Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. Purpose/Hypothesis: This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. Results: A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R2 in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs. Conclusion: Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Background: The incidence of concussions is increasing in Major League Baseball (MLB), and the cost of these injuries in 2008 was reportedly as high as US$423 million. Team officials are more aware of concussion injuries, and one measure to address this issue was the creation of a concussion-specific 7-day disabled list (DL) in 2011. Purpose: To evaluate concussion trends among MLB players and the impact of concussion-specific 7-day DL status on postinjury player performance and team financials. Study Design: Descriptive epidemiology study. Methods: From 2005 to 2016, a total of 112 players placed on the DL because of a concussion were identified using the MLB website and were verified using established news databases. Salary information for players was collected using MLB published data, and cost was calculated with a previously published formula utilizing the injured player’s salary per game and adding the cost of his replacement. Performance metrics were compared before and after the rule change. Results: The mean number of days on the DL decreased from 38.8 before 2011 to 29.2 after 2011. The mean annual cost per player before 2011 was $1.1 million and decreased to $565,000 after the rule change. Regression analyses demonstrated a downward trend in the mean cost ( R = –0.61, P < .001). A comparison of postinjury performance metrics showed no significant differences with decreased time on the DL. Conclusion: The minimum 7-day DL change has not had a negative impact on reporting; instead, it has demonstrated decreased time on the DL and lower associated team costs. Performance metrics demonstrated no differences compared with before the rule change, suggesting that players are not negatively affected by decreased time on the DL.

Vani Sabesan,1 Zachary Steffes,2 Daniel J Lombardo,1 Graysen R Petersen-Fitts,1 Toufic R Jildeh2 1Department of Orthopaedic Surgery, 2Wayne State University School of Medicine, Detroit, MI, USA Abstract: Rugby participation in the US is increasing, and with its inclusion in the 2016 Summer Olympics, the increased participation rates are expected to continue. Naturally, as participation increases, so too do rugby-related injuries. The difference in injury patterns with regard to age and gender illustrates differences in how the game is being played. Understanding what accounts for these emerging injury patterns will help guide future injury prevention efforts. This study provides an update on injury rates for the growing population of rugby players in the US, especially young players. Our results focus on the variation of injury types and the injury rates of various levels of rugby players, including youth, collegiate, and recreational. Using injury data from the National Electronic Injury Surveillance System, we analyzed data in rugby patients for age, gender, body region, type of injury, and severity. We employed statistical weights to calculate national injury estimates. During the 10years studied, the trend in the number of rugby injuries among all age groups showed a statistically significant increase (R=0.804, P=0.005). The average age of injury was 21.5±6.3years with facial and head injuries constituting >33% of all injuries, representing a proportional increase of >10%. Men were most frequently injured in the face (18.2%) and head (15.9%); women were most frequently injured in the head (23%) and shoulder (12.3%). There were 9,059 concussions, constituting 7% of all injuries. Keywords: rugby, injury pattern, epidemiology

Vani J Sabesan,1 Beau Prey,2 Ryan Smith,3 Daniel J Lombardo,3 Wilfredo J Borroto,4 James D Whaley5 1Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA; 2Western Michigan University School of Medicine, Kalamazoo, MI, USA; 3Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, MI, USA; 4Ponce School of Medicine and Health Sciences, Ponce, PR, USA; 5Beaumont Health System, Detroit, MI, USA Background: Major League Baseball (MLB) players are throwing the ball faster and hitting harder than ever before. Although some safety measures have been implemented, by decreasing the 15days on the disabled list (DL) to the 7days on the DL, concussion rates remain high across positions and may impact player performance. Our hypothesis was, there would be an increase in concussion incidence following implementation of the 7 day DL, but this would not have a negative impact on player’s postconcussion performance.Study design: This is a descriptive epidemiology study.Methods: The concussed players from 2005 to 2016 were identified from the MLB DL and verified using established new sources. Position-specific performance metrics from before and after injuries were gathered and compared to assess effects of the injury. Postconcussion performance metrics were compared before and after the 7-day DL rule implementation.Results: A total of 112 concussed players were placed on the DL. For all position players, the batting average (BA) and on-base percentage (OBP) showed a nonsignificant decline after injury (P=0.756). Although performance statistics for pitchers declined on average, the trend was not statistically significant. Postinjury BA and OBP did not significantly change before (0.355) and after (0.313) the 7-day DL rule change in 2011 (P=0.162).Conclusion: The incidence of reported concussion has increased with the 7-day DL rule change. Concussion incidence was highest in catchers and pitchers compared with all other players. The most common causes identified as being hit by pitch or struck by a foul ball or foul tip. While new league rules prevent collisions with catchers at home plate, injury by a foul tip was the most common cause for concussion. The shortened time spent on the DL did not negatively impact player’s performance. Further research on protective helmets for catchers may reduce concussion incidence. Keywords: baseball, epidemiology, head injuries/concussion, MLB, performance

Introduction Hospital readmissions after elective shoulder arthroplasty represent a costly burden to the health-care system due to the rising demand for this procedure. Nevertheless, the reasons for readmissions remain inconclusive. Therefore, the main purposes of the current investigation were to determine (1) the readmission rates within 90 days after shoulder arthroplasty, (2) the reasons behind those readmissions, and (3) the characteristics of readmitted patients. Methods A retrospective review was performed on 184 patients who underwent total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) performed by a single surgeon at a single institution between 2010 and 2016. The readmissions that occurred within 90 days after surgery and their reasons were noted. Patient characteristics were compared between readmitted and non-readmitted patients. Results Overall, 7.1% of patients were readmitted within 90 days after shoulder arthroplasty. However, patients with a previous surgery on the same shoulder of the TSA or RSA had a higher rate (13.5%) than patients without a previous surgery (5.4%). Readmission rates for TSA and RSA were virtually identical. Most readmissions were due to surgical (69.2%) rather than medical complications (30.8%). The most common reasons for readmission were surgical-site infection and deep vein thrombosis. There were no statistically significant differences between the baseline patient characteristics of readmitted and non-readmitted patients. However, the proportion of males (69.2%) was more than twice the one of females (30.8%) among readmitted patients. Conclusion The readmission rate within 90 days after surgery was relatively low among patients who underwent either a TSA or RSA at our institution. Surgically related causes were largely responsible for readmissions.

Background: The published return-to-play (RTP) rates for Major League Baseball (MLB) pitchers who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of surgical treatment for MLB players is largely unknown. Purpose: To examine the RTP rate and performance of MLB pitchers who have undergone SLAP tear repair between 2003 and 2010. Study Design: Descriptive epidemiological study. Methods: A retrospective review of MLB pitchers undergoing SLAP repair was performed using the MLB disabled list. Data collected included the following player statistics: earned run average (ERA), walks plus hits per inning pitched (WHIP), and innings pitched (IP). The mean values for performance variables both before and after surgery were compared. A definition of return to prior performance (RTPP) was established as an ERA within 2.00 and WHIP within 0.500 of preoperative values. Results: Twenty-four MLB players met inclusion criteria, of which 62.5% were able to RTP at the MLB level after SLAP repair surgery. Of those able to RTP, 86.7% were able to RTPP. However, the overall rate of RTPP, including those unable to RTP, was 54.2%. Mean performance analysis of the RTP group revealed a statistically significant decrease in IP for MLB pitchers throwing a mean 101.8 innings before injury and 65.53 innings after injury ( P = .004). Conclusion: Of those pitchers able to RTP, chances of a full recovery were good (86.7%). Our results indicate the need for future research aimed at proper surgical selection of who will return to play, as they will likely achieve full recovery. We believe this information can help surgeons advise high-level overhead-throwing athletes about expected outcomes for surgical treatment of SLAP tears.

Objectives: All-terrain vehicle (ATV) and dirt bike use is increasing in the US and is associated with risk of traumatic injury. Extremity fractures are common injures associated with these vehicles. The purpose of this study is to compare and contrast the patterns extremity fractures associated with ATVs and dirt bikes. Our hypothesis is that these different vehicles will result in similar rates of high impact injuries, but differences in vehicle stability will result in greater proportions of upper extremity fractures associated with ATV use. Methods: The National Electronic Injury Surveillance System (NEISS) was used to acquire data for extremity fractures related to ATV (3-wheels, 4-wheels, and number of wheels undefined) and dirt bike use from 2007-2012. Locations were coded as shoulder, upper arm, elbow, lower arm, wrist, hand, upper leg, knee, lower leg, ankle, foot, and toe. The data were stratified according to age and gender for each year. Incidence rates were calculated on a per vehicle basis using previous estimates of the number of ATVs and dirt bikes in the country. Results: The database yielded an estimate of 229,362.52 extremity fractures from 2007-2012. An estimated total of 130,319.20 fractures were associated with ATVs, while 99,043.37 were associated with dirt bikes. The incidence rates of extremity fractures associated with ATV and dirt bike use were 3.87 and 6.85 per 1000 vehicle-years. Most fractures were in patients 10-19 years of age, after which the number of fractures decreased with age. The largest proportion of all fractures occurred in the shoulder (27.19%), followed by the wrist and lower leg (13.77% and 12.36%, respectively). This distribution of fractures was consistent among ATV use for all age groups except in the 0-9 year olds, where the lower arm and wrist were the most commonly fractured locations. Fracture distribution associated with dirt bike use also followed this general pattern, with the exception of 0-9 and 10-19 year olds having increased proportions of lower arm fractures. When comparing the genders, males had much larger proportions of fractures than females at all locations, except for the upper arm. When comparing the specific injury locations for different vehicle types, there were no differences in the distribution of the location of fractures among 4-wheeled or unspecified ATVs. However, 3-wheeled ATVs and dirt bikes had much larger proportion of lower leg, foot and ankle fractures compared to the other vehicle types. Conclusion: Extremity fractures are among the most common type of injury resulting from ATV and dirt bike use. Our results demonstrated a pattern of injury where the shoulder and lower arm were the most commonly injured locations. This pattern was inconsistent among females, the very young, and 3 wheeled ATVs and dirt bikes. These differences could be due to both rider related factors and vehicle design factors. Knowing commonly fractured locations, the use of additional protective equipment specific to these injuries may be beneficial. Additionally, participants should be cautioned of the increased risk of fractures associated with dirt bike use, as well as the unusual pattern of injuries of 3-wheeled ATVs implying instability of these vehicles.

Synovial lipomatosis is a benign proliferative disease of the subsynovial adipose which can lead to a variety of presentations. Cases of synovial lipomatosis in children or adolescents are rare. This case report describes an adolescent patient with a rare bilateral presentation of synovial lipomatosis. She had been treated for years prior to her presentation for juvenile idiopathic arthritis. She presented with chronic bilateral knee pain, swelling, and mechanical symptoms. Bilateral MR imaging demonstrated effusions, hypertrophy of the synovium, and polyp-like projections of tissue with the same signal intensity as fat which is pathognomonic for synovial lipomatosis. Arthroscopic synovectomy and extensive debridement of polyp like fat projections of the right knee was performed. Histopathology was consistent with the synovial lipomatosis diagnosis. Postoperatively, the patient was satisfied with her outcome with improved pain relief and function in her right knee.

[Introduction][1] We describe a bone-graft technique, for shoulder arthroplasty in patients with severe glenoid bone loss, that utilizes a “step cut,” a trapezoidal bone wedge from the resected humeral head, and graft fixation with screws placed from posterior to anterior through the graft. [Step 1: Preoperative Planning][2] Carry out preoperative planning for the step-cut procedure. [Step 2: Surgical Approach and Preparation of the Glenoid][3] Expose the glenoid for bone graft insertion, taking care to avoid excessive reaming. [Step 3: Prepare the Glenoid Bone Graft][4] Cut the appropriately sized glenoid bone graft from the resected humeral head. [Step 4: Insert and Fix the Glenoid Bone Graft][5] Position the bone graft in the glenoid defect and stabilize it with screws. [Step 5: Prepare the Glenoid Surface][6] Create an even concave surface between the anterior aspect of the glenoid and the posterior aspect of the graft. [Step 6: Place the Glenoid Implant][7] Position the glenoid component following step-cut graft implantation. [Postoperative Rehabilitation][8] Postoperative rehabilitation is mostly the same as that for standard total shoulder replacement without bone-grafting. [Results][9] The range of motion improved significantly in our study of twelve patients (p < 0.001). [Indications][10] [Contraindications][11] [Pitfalls & Challenges][12] [Introduction][1] We describe a bone-graft technique, for shoulder arthroplasty in patients with severe glenoid bone loss, that utilizes a “step cut,” a trapezoidal bone wedge from the resected humeral head, and graft fixation with screws placed from posterior to anterior through the graft. [Step 1: Preoperative Planning][2] Carry out preoperative planning for the step-cut procedure. [Step 2: Surgical Approach and Preparation of the Glenoid][3] Expose the glenoid for bone graft insertion, taking care to avoid excessive reaming. [Step 3: Prepare the Glenoid Bone Graft][4] Cut the appropriately sized glenoid bone graft from the resected humeral head. [Step 4: Insert and Fix the Glenoid Bone Graft][5] Position the bone graft in the glenoid defect and stabilize it with screws. [Step 5: Prepare the Glenoid Surface][6] Create an even concave surface between the anterior aspect of the glenoid and the posterior aspect of the graft. [Step 6: Place the Glenoid Implant][7] Position the glenoid component following step-cut graft implantation. [Postoperative Rehabilitation][8] Postoperative rehabilitation is mostly the same as that for standard total shoulder replacement without bone-grafting. [Results][9] The range of motion improved significantly in our study of twelve patients (p < 0.001). [Indications][10] [Contraindications][11] [Pitfalls & Challenges][12] [1]: #sec-11 [2]: #sec-12 [3]: #sec-13 [4]: #sec-14 [5]: #sec-15 [6]: #sec-16 [7]: #sec-17 [8]: #sec-18 [9]: #sec-19 [10]: #sec-21 [11]: #sec-22 [12]: #sec-23

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.