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Background: Posterior glenoid bone loss is commonly associated with primary glenohumeral osteoarthritis. Surgical management of bone loss in anatomic total shoulder arthroplasty (aTSA) remains controversial. We studied the use of a stepped augmented glenoid component for management of Walch B2 and B3 glenoids and compared the radiographic and clinical outcomes at short-term follow-up with those achieved with a non-augmented component of the same design in Walch A1 glenoids.Methods: Ninety-two patients (42 A1, 29 B2, and 21 B3 glenoids) were prospectively followed after aTSA. Sequential 3-dimensional (3D) computed tomography (CT) imaging was performed preoperatively, within 3 months postoperatively with metal artifact reduction (MAR) to define implant position, and at a minimum of 2 years postoperatively with MAR. Scapular 3D registration with implant registration allowed 3D measurement of glenoid implant position, implant shift, and central peg osteolysis (CPO).Results: CPO with or without implant shift occurred in a higher percentage of B3 glenoids treated with the augmented glenoid component (29%) than A1 glenoids treated with a standard component (5%) (p = 0.028). There was no significant difference in the frequency of CPO between B2 glenoids with the augmented component (10%) and A1 glenoids with the standard component. There was no difference in postoperative glenoid component version and inclination between groups. B3 glenoids were associated with more component medialization relative to the premorbid joint line compared with A1 and B2 glenoids (p < 0.001).Conclusions: A stepped augmented glenoid component can restore premorbid glenoid anatomy in patients with asymmetric biconcave glenoid bone loss (Walch B2), with short-term clinical and radiographic results equivalent to those for patients without glenoid bone loss (Walch A1) treated with a non-augmented component. There is a greater risk of CPO in patients with moderate-to-severe B3 glenoid pathology with this stepped augmented glenoid component. Longer follow-up will help define the clinical implications of CPO over time.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The purpose of this study was to demonstrate the validity and efficiency of the Outcomes Management and Evaluation (OME) system, a prospectively designed electronic data collection tool, for collecting comprehensive and standardized surgical data in shoulder arthroplasty. Surgical data from the first 100 cases of shoulder arthroplasty that were collected into the OME database were analyzed. Surgeons completed a traditional narrative operative note and also an OME case report using an encrypted smartphone. A blinded reviewer extracted data from the operative notes and implant logs in the electronic medical records (EMR) by manual chart review. OME and EMR data were compared with regard to data counts and agreement between 39 variables related to preoperative pathology, including rotator cuff status and glenoid wear, and surgical procedures. Data counts were assessed using both raw percentages and with McNemar's test (with continuity correction). Agreement of nominal variables was analyzed using Cohen's unweighted kappa (κ) and of ordinal variables using the linearly weighted Cohen's test. Efficiency was assessed by calculating the median time needed to complete OME. Compared to the EMR, the OME database had significantly higher data counts for 56% (22 of 39) of the variables assessed. A high level of proportional and statistical agreement was demonstrated between the data in the 2 datasets. Ten of 39 variables had 100% agreement but could not be statistically compared because both datasets had the same single response under those variables. Among the 29 variables that were compared, 79% (23 of 29) of variables had >80% raw proportional agreement, and 69% (20 of 29) of variables showed at least substantial agreement (κ > 0.6). The median time for completing OME surgery data entry was 92 seconds (IQR 70-126). The prospectively designed, electronic data entry system (OME) is an efficient and valid tool for collecting comprehensive and standardized surgical data on shoulder arthroplasty. Level IV; Case series; Diagnostic study [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis.Methods: In a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component, sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). Glenoid component shift was defined as a change in component version or inclination of ≥3° from CT2 to CT3. Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. Factors associated with glenoid component shift and CPO were evaluated.Results: Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift. Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO. B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. Neither glenoid component shift nor CPO was associated with worse clinical outcomes.Conclusions: Postoperative 3D CT analysis demonstrated that glenoid component shift commonly occurs following anatomic TSA, with increased inclination the most common direction. Most (81%) of the patients with glenoid component shift did not develop CPO. Longer follow-up is needed to determine the relationships of glenoid component shift and CPO with loosening over time.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Cases: Two patients presented to different surgeons complaining of persistent shoulder pain after reverse total shoulder arthroplasty. Workups for fracture, instability, and periprosthetic infection were negative. Advanced imaging, nerve conduction studies, and diagnostic injections localized symptoms to the suprascapular nerve. Revision arthroplasty with removal of the offending screws improved pain in both patients. Conclusion: Suprascapular nerve irritation because of the malposition of baseplate screws in reverse total shoulder arthroplasty can be a source of postoperative pain. Removal of the offending screw without formal nerve exploration may result in symptomatic improvement. [ABSTRACT FROM AUTHOR]

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 R 2 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. [ABSTRACT FROM AUTHOR]

This study tested validity and efficiency of Orthopaedic Minimal Data Set (OrthoMiDaS) Episode of Care (OME). We analyzed 100 isolated rotator cuff repair cases in the OME database. Surgeons completed a traditional operative note and OME report. A blinded reviewer extracted data from operative notes and implant logs in electronic medical records by manual chart review. OME and electronic medical record data were compared with data counts and agreement between 40 variables of rotator cuff disease and repair procedures. Data counts were assessed using raw percentages and McNemar test (with continuity correction). Agreement of categorical variables was analyzed using Cohen κ (unweighted) and of numerical variables using the concordance correlation coefficient (CCC). Efficiency was assessed by median time to complete. OME database had significantly higher data counts for 25% (10/40) of variables. A high level of proportional and statistical agreement was demonstrated between the data. Among 35 categorical variables, proportional agreement was perfect for 17%, almost perfect (0.81 ≤ κ ≤ 1.00) for 37%, substantial (0.61 ≤ κ ≤ 0.80) for 20%, moderate (0.41 ≤ κ ≤ 0.60) for 14%, fair (0.21 ≤ κ ≤ 0.40) for 6%, and slight (0.0 ≤ κ ≤ 0.20) for 6%. Of 5 numerical variables, agreement was almost perfect (CCC > 0.99) for 20% and poor (CCC < 0.90) for 80%. Median OME completion time was 161.5 seconds (interquartile range, 116-224.5). OME is an efficient, valid tool for collecting comprehensive, standardized data on rotator cuff repair. [ABSTRACT FROM AUTHOR]

Background: Use of 3-dimensional (3D) computed tomography (CT) preoperative planning and patient-specific instrumentation has been demonstrated to improve the accuracy of glenoid implant placement in total shoulder arthroplasty (TSA). The purpose of this study was to compare the accuracy of glenoid implant placement in primary TSA among different types of instrumentation used with the 3D CT preoperative planning.Methods: One hundred and seventy-three patients with end-stage glenohumeral arthritis were enrolled in 3 prospective studies evaluating patient-specific instrumentation and 3D preoperative planning. All patients underwent preoperative 3D CT planning to determine optimal glenoid component and guide pin position based on surgeon preference. Patients were placed into 1 of 5 instrument groups used for intraoperative guide pin placement: (1) standard instrumentation, (2) standard instrumentation combined with use of a 3D glenoid bone model containing the guide pin, (3) use of the 3D glenoid bone model combined with single-use patient-specific instrumentation, (4) use of the 3D glenoid bone model combined with reusable patient-specific instrumentation, and (5) use of reusable patient-specific instrumentation with an adjustable, reusable base. Postoperatively, all patients underwent 3D CT to compare actual versus planned glenoid component position. Deviation from the plan (in terms of orientation and location) was compared across groups on the basis of absolute differences and outlier analysis. Univariable and multivariable comparisons were performed. As the initial analyses showed no significant differences in preoperative factors or in deviation from the plan between Groups 1 and 2 or between Groups 4 and 5 across studies, the final analysis was across 3 major treatment groups: standard instrumentation (Groups 1 and 2), single-use patient-specific instrumentation (Group 3), and reusable patient-specific instrumentation (Groups 4 and 5).Results: In nearly all comparisons, there were no significant differences in the deviation from the plan (absolute differences or outlier frequency) for glenoid implant orientation or location across the 3 major treatment groups.Conclusions: This study did not demonstrate that any type of patient-specific instrumentation resulted in consistent differences in accuracy of glenoid implant placement in primary TSA with 3D CT preoperative planning. Surgeons have multiple patient-specific instrumentation options available for improving accuracy of glenoid implant placement when compared with 2D imaging without patient-specific instrumentation.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used. Methods Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used. Results A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair. Conclusions Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods. [ABSTRACT FROM AUTHOR]

Background Revision shoulder arthroplasty in the setting of glenoid bone loss poses substantial surgical challenges. This study's purpose was to compare radiographic and clinical results of patients requiring structural iliac crest bone autograft (ICBA) for severe bone loss versus patients with less severe bone loss treated with nonstructural bone allograft (NSBA) in the setting of revision reverse total shoulder arthroplasty (RSA). Methods A retrospective cohort of 30 patients (70% of the 43 patients who met the inclusion criteria) undergoing revision RSA with ICBA (n = 15) or NSBA (n = 15) between 2007 and 2015 were analyzed at a minimum 2-year follow-up. Radiographic assessment included bone graft integration, bone graft resorption, glenosphere tilt, glenosphere version, and the presence of scapular notching. Clinical assessment included active range of motion, Penn Shoulder Score, Veterans RAND 12-item health survey, and need for revision surgery. Results No radiographic difference was found between the ICBA and NSBA groups with regard to implant position, graft integration, scapular notching, implant shift, or failure of fixation (P >.05). Of 15 patients with ICBA, 14 (93%) had at least partial integration of the bone graft. Some degree of resorption of the bone graft was noted in 6 of 15 patients (40%). There was no significant difference in postoperative active range of motion, Penn Shoulder Score, or Veterans RAND 12-item health survey score (P >.05 for all comparisons). One patient in the ICBA group underwent revision surgery for glenoid baseplate failure. Conclusion Revision RSA with glenoid bone grafting resulted in good clinical and radiographic outcomes at short-term follow-up. Patients requiring structural ICBA were not at increased risk of component failure, radiographic or clinical complications, or inferior clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Mobile technology offers the prospect of delivering high-value care with increased patient access and reduced costs. Advances in mobile health (mHealth) and telemedicine have been inhibited by the lack of interconnectivity between devices and software and inability to process consumer sensor data. The objective of this study was to preliminarily validate a motion-based machine learning software development kit (SDK) for the shoulder compared with a goniometer for 4 arcs of motion: (1) abduction, (2) forward flexion, (3) internal rotation, and (4) external rotation. Methods A mobile application for the SDK was developed and “taught” 4 arcs of shoulder motion. Ten subjects without shoulder pain or prior shoulder surgery performed the arcs of motion for 5 repetitions. Each motion was measured by the SDK and compared with a physician-measured manual goniometer measurement. Angular differences between SDK and goniometer measurements were compared with univariate and power analyses. Results The comparison between the SDK and goniometer measurement detected a mean difference of less than 5 ° for all arcs of motion ( P  > .05), with a 94% chance of detecting a large effect size from a priori power analysis. Mean differences for the arcs of motion were: abduction, −3.7° ± 3.2°; forward flexion, −4.9° ± 2.5°; internal rotation, −2.4° ± 3.7°; and external rotation −2.6° ± 3.4°. Discussion The SDK has the potential to remotely substitute for a shoulder range of motion examination within 5° of goniometer measurements. An open-source motion-based SDK that can learn complex movements, including clinical shoulder range of motion, from consumer sensors offers promise for the future of mHealth, particularly in telemonitoring before and after orthopedic surgery. [ABSTRACT FROM AUTHOR]

Social media provide a unique method of analyzing outcomes and quality in medicine. The purpose of this observational study was to investigate the nature of social media content related to shoulder and elbow (S&E) surgery posted by patients, surgeons, and hospitals. A public search of Instagram for a twoyear period yielded 1,177 patient-related posts. A categorical system assessed the perspective, timing, tone, and content of each post. Twitter accounts of 77 S&E specialists from the top five ranked U.S. News & World Report institutions were analyzed for activity and content. 5,246 Twitter and Instagram posts for the institutions were analyzed for frequency and content. Most patient-related posts were by patients (68 %), postoperative (82 %), positive (87 %), and centered on return-toplay for Tommy John (34 %), surgical site for shoulder arthroplasty (52 %), and activities of daily living for rotator cuff repair (22 %). 37 % of surgeons had active accounts averaging 46 posts, 87 % of which were practice advertisements. Hospitals averaged 273 posts over the 2-year period, focusing on education (38 %) and community (18 %). S&E patients share outcomes on social media in a positive tone with proceduredependent emphases. Surgeons on social media use sites for practice augmentation. Hospitals often focused posts towards educating the community. [ABSTRACT FROM AUTHOR]

Background Whereas several studies suggest that high-volume surgeons and hospitals deliver superior patient outcomes with greater cost efficiency, no evidence-based thresholds separating high-volume surgeons and hospitals from those that are low or medium volume exist in shoulder arthroplasty. The objective of this study was to establish meaningful thresholds that take outcomes and cost into consideration for surgeons and hospitals performing shoulder arthroplasty. Methods Using 9546 patients undergoing primary shoulder arthroplasty for osteoarthritis from an administrative database, we created and applied 4 models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated 4 sets of thresholds predictive of adverse outcomes, namely, increased length of stay (LOS) and increased cost for both surgeon and hospital volume. Results SSLR analysis of the 4 ROC curves by surgeon volume produced 3 volume categories. LOS and cost by annual shoulder arthroplasty surgeon volume produced the same strata: 0-4 (low), 5-14 (medium), and 15 or more (high). LOS and cost by annual shoulder arthroplasty hospital volume produced the same strata: 0-3 (low), 4-14 (medium), and 15 or more (high). LOS and cost decreased significantly ( P  < .05) in progressively higher volume categories. Conclusions Our study validates economies of scale in shoulder arthroplasty by demonstrating a direct relationship between volume and value through SSLR analysis of ROC curves for risk-based volume stratification using meaningful volume definitions for low-, medium-, and high-volume surgeons and hospitals. The described volume-value relationship offers patients, surgeons, hospitals, and other stakeholders meaningful thresholds for the optimal delivery of shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Scaffolds continue to be developed and used for rotator cuff repair augmentation, but clinical or biomechanical data to inform their use are limited. We have developed a reinforced fascia lata patch with mechanical properties to meet the needs of musculoskeletal applications. The objective of this study was to assess the extent to which augmentation of a primary human rotator cuff repair with the reinforced fascia patch can reduce gap formation during in vitro cyclic loading. Materials and methods: Nine paired human cadaveric shoulders were used to investigate the cyclic gap formation and failure properties of augmented and non-augmented rotator cuff repairs with loading of 5 to 180 N for 1000 cycles. Results: Augmentation significantly decreased the amount of gap formation at cycles 1, 10, 100, and 1000 compared with non-augmented repairs (P < .01). The mean gap formation of the augmented repairs was 1.8 mm after the first cycle of pull (vs 3.6 mm for non-augmented repairs) and remained less than 5 mm after 1000 cycles of loading (4.7 mm for augmented repairs vs 7.3 mm for non-augmented repairs). Furthermore, all augmented repairs were able to complete the 1000-cycle loading protocol, whereas 3 of 9 non-augmented repairs failed before completing 1000 loading cycles. Conclusions: This study supports further investigation of reinforced fascia patches to provide mechanical augmentation, minimize tendon retraction, and possibly reduce the incidence of rotator cuff repair failure. Future investigation in animal and human studies will be necessary to fully define the efficacy of the reinforced fascia device in a biologic healing environment. [ABSTRACT FROM AUTHOR]

Background: Scaffolds continue to be developed and used for rotator cuff repair augmentation; however, the appropriate scaffold material properties and/or surgical application techniques for achieving optimal biomechanical performance remains unknown. The objectives of the study were to simulate a previously validated spring-network model for clinically relevant scenarios to predict: (1) the manner in which changes to components of the repair influence the biomechanical performance of the repair and (2) the percent load carried by the scaffold augmentation component. Materials and methods: The models were parametrically varied to simulate clinically relevant scenarios, namely, changes in tendon quality, altered surgical technique(s), and different scaffold designs. The biomechanical performance of the repair constructs and the percent load carried by the scaffold component were evaluated for each of the simulated scenarios. Results: The model predicts that the biomechanical performance of a rotator cuff repair can be modestly increased by augmenting the repair with a scaffold that has tendon-like properties. However, engineering a scaffold with supraphysiologic stiffness may not translate into yet stiffer or stronger repairs. Importantly, the mechanical properties of a repair construct appear to be most influenced by the properties of the tendon-to-bone repair. The model suggests that in the clinical setting of a weak tendon-to-bone repair, scaffold augmentation may significantly off-load the repair and largely mitigate the poor construct properties. Conclusions: The model suggests that future efforts in the field of rotator cuff repair augmentation may be directed toward strategies that strengthen the tendon-to-bone repair and/or toward engineering scaffolds with tendon-like mechanical properties. [ABSTRACT FROM AUTHOR]

Background: Recent studies have detailed the significance of indolent infections in revision shoulder arthroplasty, but little information is available to guide treatment strategies regarding patients with positive cultures without overt signs of infection. The primary purpose of this study was to determine recurrence rates of infection for patients undergoing revision shoulder arthroplasty who were not treated for infection but had positive intraoperative cultures. Materials and methods: We retrospectively reviewed the results of 17 patients undergoing revision of a failed shoulder joint replacement with at least 1 positive intraoperative culture who were not treated for infection because of limited signs of infection before or at the time of revision surgery. These patients underwent 1-stage revision surgery without an extended intravenous antibiotic regimen. Results: The recurrence rate of infection for the 17 patients was 5.9%. The most common pathogen cultured at revision surgery was Propionibacterium acnes (10 of 17 [56%]), followed by coagulase-negative Staphylococcus species (6 of 17 [35%]). Conclusion: We found that low-virulence and clinically unexpected infections treated with 1-stage revision have a low risk for recurrent infection. This study suggests that intensive antimicrobial treatment strategies may not be necessary to reduce recurrent infections in patients with positive intraoperative cultures, without overt clinical signs of infection before or during the revision surgery. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to investigate further the effect of medical comorbidity on a patient reported shoulder specific health related quality of life (HRQoL) measure. We investigated which types of comorbidities have a detrimental effect upon shoulder specific HRQoL. We hypothesized that general medical comorbidity would not negatively affect shoulder specific HRQoL questionnaires, but that comorbidities specific to the chest region would, when properly controlling for other patient factors. Methods: A cohort of 173 consecutive patients who underwent shoulder surgery for osteoarthritis and/or rotator cuff repair was extracted from a clinical outcomes database. Their health related quality of life (HRQoL) was evaluated with the University of Pennsylvania (PENN) shoulder score and the Short Form-36 (SF-36). Nonadjusted and multivariate risk-adjusted models were built to investigate the effect of medial comorbidity on shoulder specific HRQoL and were tested using linear modeling. Results: Nonadjusted models showed patients with more total comorbidities (P =.01) and more chest-related comorbidities (P =.006) had lower PENN scores. But, when risk adjusting for other patient factors, the PENN scores decreased with an increase in the number of chest comorbidities (P =.008), but not the number of total comorbidites (P =.391) or other (nonchest) comorbidities (P =.163). Conclusion: Shoulder specific HRQoL measures are joint specific, but they are influenced by disease or conditions that affect the chest region. This may be important in understanding why patients with certain comorbid diseases report worse shoulder pain and function and may respond differently to treatment over time. [ABSTRACT FROM AUTHOR]

Background: Recently, a lesser tuberosity osteotomy has been promoted as an alternative to tenotomy for release of the subscapularis during shoulder arthroplasty. To our knowledge, no direct comparison of the clinical results of the two techniques has been presented. Methods: Thirty-five shoulders in thirty-four consecutive patients with osteoarthritis who had a primary total shoulder arthroplasty, performed with use of a standard subscapularis tenotomy (Group 1) or lesser tuberosity osteotomy (Group 2) to release the subscapularis, were evaluated retrospectively at an average of thirty-three months. Group 1 consisted of fifteen shoulders in fourteen patients (seven in males and eight in females, with an average age of sixty-seven years). Group 2 consisted of twenty shoulders in twenty patients (fourteen males and six females, with an average age of sixty-nine years). Assessment included a physical examination, clinical outcome questionnaires, conventional radiography, ultrasound examination of the subscapularis, and measurement of internal rotation strength. Results: The postoperative total Penn Shoulder Scores improved significantly from the preoperative levels in both groups (mean and standard deviation, 29 ± 15 points to 81 ± 20 points [p < 0.00001] in Group 1 and 29 ± 16 points to 92 ± 11 points [p < 0.00001] in Group 2). However, the postoperative mean total Penn Shoulder Score was higher in Group 2 (92 ± 11 points) than in Group 1 (81 ± 20 points) (p = 0.04). At one year, an abnormal subscapularis on ultrasound was associated with a lower mean Penn Shoulder Score in Group 1 (73 ± 19 points compared with 92 ± 3 points; p = 0.01). However, at a minimum two-year follow-up, this difference was not significant (mean, 74 ± 24 points and 86 ± 15 points, respectively; p = 0.25). There were more abnormal subscapularis tendons in Group 1 (six attenuated tendons and one full-thickness tear) than in Group 2 (two attenuated tendons). Internal rotation strength did not differ between the groups when controlled for sex (mean, 117 ± 8 N and 127 ± 21 N for males in Group 1 and Group 2, respectively [p = 0.22] and 77 ± 27 N and 101 ± 26 N, respectively, for females [p = 0.1]). Conclusions: Both techniques resulted in improved clinical outcome scores. The lesser tuberosity osteotomy resulted in higher clinical outcome scores, a lower rate of subscapularis tendon tears, and universal healing of the osteotomy. This technique offers a means by which the rate of postoperative subscapularis tears may be reduced in patients undergoing total shoulder arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Hypothesis: Rotator cuff repair failure rates range from 20% to 90%, and failure is believed to occur most commonly by sutures cutting through the tendon due to excessive tension at the repair site. This study was designed to determine whether application of a woven poly-L-lactic acid device (X-Repair; Synthasome, San Diego, CA) would improve the mechanical properties of rotator cuff repair in vitro. Materials and methods: Eight pairs of human cadaveric shoulders were used to test augmented and non-augmented rotator cuff repairs. Initial stiffness, yield load, ultimate load, and failure mode were compared. Results: Yield load was 56% to 92% higher and ultimate load was 56% to 76% higher in augmented repairs. No increase in initial stiffness was found. Failure by sutures cutting through the tendon was reduced, occurring in 17 of 20 non-augmented repairs but only 7 of 20 augmented repairs. Conclusions: Our data show that application of the X-Repair device significantly increased the yield load and ultimate load of rotator cuff repairs in a human cadaveric model and altered the failure mode but did not affect initial repair stiffness. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to review the results of a relatively homogenous group of patients with glenohumeral subluxation without labral pathology who were treated with an electrothermal capsulorrhaphy procedure. Type of Study: Case series without controls. Methods: From 1997 to 1998, 42 patients underwent electrothermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). Patients with prior capsular repairs, labral pathology that required repair, or capsular avulsion injuries were excluded from the study. Thirty-one patients met the inclusion criteria. Patients had a minimum of 2 years of follow-up (mean, 25 months), and a mean age of 25 years (range, 16 to 38 years). All of the patients had previously failed conservative treatment. There were 25 patients with unidirectional anterior instability, 2 patients with unidirectional inferior instability, 1 patient with unidirectional posterior instability, and 3 patients with multidirectional instability. The patients were assessed using a modified American Shoulder and Elbow Surgeons (ASES) score that examined pain (30 points), function (60 points), and patient satisfaction (10 points). In addition, subjective stability was assessed using a 10-point scale. Results: The average modified ASES score increased to 88 points from 56 preoperatively (P < .01). The average subjective stability scale increased to 8.5 from 4.4 preoperatively (P < .01). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result; 22 of 26 patients who participated in sports were able to return to their preinjury level of play. The subset of patients with isolated anterior instability had results similar to the overall group. There were no instances of axillary neuritis or other neurologic injury. Conclusions: In carefully selected patients with shoulder instability, including unidirectional anterior instability without associated labral pathology, electrothermal capsulorrhaphy was effective and had few complications. Level of Evidence: Level IV, case series without controls. [Copyright &y& Elsevier]

Background: This prospective multi-institutional study was designed to define the accuracy of ultrasonography, when performed in an orthopaedic surgeon's office, for the diagnosis of rotator cuff tears. Methods: An anatomic diagnosis and a treatment plan were made on the basis of office-based shoulder ultrasonography, physical examination, and radiographs for ninety-eight patients (ninety-nine shoulders) with a clinical diagnosis of a rotator-cuff-related problem. The results of the ultrasonographic studies were then compared with the results of magnetic resonance imaging and the operative findings. Results: Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness tears, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear only, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach (open or arthroscopic) that had been planned on the basis of the ultrasonography altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic cuff repair in four shoulders. Magnetic resonance imaging led to the correct diagnosis for forty (95%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness rotator cuff tears, twenty-seven (73%) of thirty-seven shoulders with only a partial-thickness tear, and fifteen (75%) of twenty shoulders with normal tendons. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting tear size in the anteriorposterior dimension was 86% (95% confidence interval, 71% to 95%), and that of magnetic resonance imaging was 93% (95% confidence interval, 81% to 99%) (p = 0.26). The sensitivity of ultrasonography for detecting tear size in the medial-lateral dimension was 83% (95% confidence interval, 69% to 93%), and that of magnetic resonance imaging was 88% (95% confidence interval, 74% to 96%) (p = 0.41). Conclusions: A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination and a review of shoulder radiographs, to accurately diagnose the extent of rotator cuff tears in patients suspected of having such tears. Errors in diagnosis made on the basis of ultrasonography most often consist of an inability to distinguish between partial and full-thickness tears that are approximately 1 cm in size. In this study, such errors did not significantly affect the planned surgical approach. Level of Evidence: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article discusses the study in which eccentric loading and glenoid component retroversion shows as a significant mechanism that leads to glenoid component loosening. The study uses 66 shoulders as subjects that underwent total shoulder displacement with an all-polyethylene press-fit pegged glenoid component that was designed for osseous ingrowth for osteoarthritis treatment. Results shows that 30 percent of the 66 shoulders had osteolysis around the center peg.

Management of glenoid bone loss in shoulder arthroplasty is challenging. Currently available prosthetic, biologic, and composite prosthetic and biologic solutions are not ideal. The most common solutions involve a combination of asymmetric reaming, bone grafting, and standard polyethylene components. The development of additional prosthetic and biologic solutions may require a change in the way glenoid bone loss and component fixation are conceptualized. Classifications should be modified to consider the portions of the glenoid still remaining for fixation. In addition, the concept of placing glenoid components in the glenoid vault rather than on the subchondral surface, which is often deficient, should be developed. These changes may result in mass-produced glenoid components that could make management of glenoid bone loss more reproducible. [Copyright &y& Elsevier]

Rotator cuff tears, a common source of shoulder pathology, are often the cause of debilitating shoulder pain, reduced shoulder function and compromised joint mechanics. The treatment, evaluation and management of this disease puts an annual financial burden of 3 billion US dollars on the US economy. Despite surgical advances, there is a high rate of recurrent tears ranging (20-70%) after surgical repair, particularly for chronic, large to massive cuff tears. The inability to obtain a high healing rate in these tears has fueled investigation in the use of extracellular matrix (ECM) derived materials as a scaffolds for rotator cuff tendon repair and regeneration. The present paper reviews the current state of knowledge regarding the mechanical and biological characteristics of commercially available ECM materials, delineates indications for their clinical use and suggests future directions in developing ECM scaffolds for rotator cuff repair. [Copyright &y& Elsevier]