Search

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 two-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI).A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by two fellowship-trained shoulder surgeons at two separate institutions from August, 2016 to August, 2019 was performed. Minimum follow up was two years. Range of motion (ROM), Visual Analog Pain Scores (VAS), 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 three independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up.Seventy-five shoulders were included for 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, six (8%) were type B3 and three (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 to 0.9, p0.001), SANE (39.5 to 91.2, p0.001) and ASES (43.7 to 86.6, p0.001) scores were observed. There were four (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) cases of glenoid loosening. No revisions were performed for glenoid loosening.At a minimum of two years postoperatively, there were significant improvements in ROM and 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.

During anatomic total shoulder arthroplasty (aTSA), the humeral head can be resected with or without the use of an intramedullary cutting guide, the former referred to as intramedullary (IM) resection and the latter referred to as freehand (FH) resection. Outcomes following aTSA are predicated upon the restoration of the native humeral anatomy, which can be more challenging with stemless implants. To date, no studies have determined which method of humeral head resection is superior in restoring native anatomy. Our purpose was to determine whether FH or IM resection was superior in restoring native anatomy during aTSA with stemless implants.A review of all patients who underwent aTSA using the stemless Tornier Simpliciti Shoulder System at two academic institutions by two separate surgeons between January 2017 and June 2020 was performed. One surgeon at one institution performed stemless aTSA using the IM resection technique, while the second surgeon utilized the FH resection technique. Patients were excluded if they underwent surgery for an indication other than glenohumeral osteoarthritis, if they received a short-stem or standard-stem implant, or if they lacked adequate preoperative and postoperative Grashey radiographs. One hundred eleven patients across both institutions (51 IM, 60 FH) were included for the final radiographic assessment. The humeral head height (HH) and neck-shaft angle (NSA) were measured on preoperative and postoperative Grashey radiographs. The centers of rotation (CORs) were measured on postoperative Grashey radiographs. Patients were classified as having acceptable restoration of their native anatomy if the change (Δ) in COR or HH was ≤3 mm and ≤ 5 mm, respectively, or if the postoperative NSA was ≥130°.IM resection had the greatest acceptable restoration of COR (90.2% IM versus 70% FH, P = .009), HH (96.1% IM vs. 63.3% FH, P .001), and NSA (96.1% IM vs. 78.3% FH, P = .006) relative to FH resection. The mean postoperative NSAs for the IM and FH cohorts were 134.4° (±2.1°) and 133.8° (±5.4°), respectively (P = .208). The mean ΔCORs for the IM and FH groups were 1.2 (±1.5) and 2.3 (±1.2) mm, respectively (P .001). Finally, the mean ΔHHs for the IM and FH cohorts were 1.7 (±1.4) and 4.4 (±2.9) mm, respectively (P .001).Restoration of the native humeral anatomy following stemless aTSA occurred at a significantly higher rate when using IM vs. FH resection.

The purpose of this study was to establish emergency department (ED) utilization rate and reasons for presentation to the ED after outpatient rotator cuff repair (RCR) and determine preoperative predictors for these ED visits.Patients who underwent outpatient RCR between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and stratified. Univariate and multivariate analyses were done to identify independent predictors of ED utilization.The 7- and 30-day ED visit rates were 3.2% and 5.0%, respectively. The most common cause for an ED visit after outpatient RCR at 7- and 30-days postoperatively were postoperative pain (29.0%) and GI complaints (16.3%), respectively. African American race (odds ratio [OD], 1.69; P0.001), Hispanic race (OD, 1.47; P = 0.005), and comorbid diagnoses of hypertension (OD, 1.51; P0.001), diabetes (OD, 1.58; P0.001), and/or schizophrenia (OD, 5.14; P0.001) were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare (OD, 2.01; P0.001) or Medicaid (OD, 2.61; P0.001) were more than twice as likely to present to the ED within 30 days than those with private health insurance.ED utilization after outpatient RCR is uncommon with postoperative pain as the most common chief concern for ED visits within the first 7 days and GI issues as the most common reason for ED encounters at up to 30 days postoperatively. Hypertension, diabetes, renal failure, liver disease, rheumatologic diseases, schizophrenia, depression, and Medicare and Medicaid insurance were independent predictors of ED encounters at up to 30 days postoperatively. Procedures done at freestanding surgery centers were protective against ED utilization.Level III, Retrospective Cohort.

The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, “authorizations”), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 “subspecialty” groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [ Orthopedics . 2023;46(2):e98–e104.]

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Background: Successful management of massive rotator cuff (RC) tendon tears represents a treatment challenge because of the limited intrinsic healing capacity of native tendons and the risk of repair failure. Biologic augmentation of massive RC tears utilizing scaffolds—capable of regenerating bulk tendon tissue to achieve a mechanically functional repair—represents an area of increasing clinical interest. Purpose: To investigate the histological and biomechanical outcomes after the use of a novel biologic scaffold fabricated from woven electrochemically aligned collagen (ELAC) threads as a suture-holding, fully load-bearing, defect-bridging scaffold with or without mesenchymal stem cells (MSCs) compared with direct repair in the treatment of critically sized RC defects using a rabbit model. Study Design: Controlled laboratory study. Methods: A total of 34 New Zealand White rabbits underwent iatrogenic creation of a critically sized defect (6 mm) in the infraspinatus tendon of 1 shoulder, with the contralateral shoulder utilized as an intact control. Specimens were divided into 4 groups: (1) gap—negative control without repair; (2) direct repair of the infraspinatus tendon—operative control; (3) tendon repair using ELAC; and (4) tendon repair using ELAC + MSCs. Repair outcomes were assessed at 6 months using micro–computed tomography, biomechanical testing, histology, and immunohistochemistry. Results: Specimens treated with ELAC demonstrated significantly less tendon retraction when compared with the direct repair group specimens ( P = .014). ELAC + MSCs possessed comparable biomechanical strength (178 ± 50 N) to intact control shoulders (199 ± 35 N) ( P = .554). Histological analyses demonstrated abundant, well-aligned de novo collagen around ELAC threads in both the ELAC and the ELAC + MSC shoulders, with ELAC + MSC specimens demonstrating increased ELAC resorption (7% vs 37%, respectively; P = .002). The presence of extracellular matrix components, collagen type I, and tenomodulin, indicating tendon-like tissue formation, was appreciated in both the ELAC and the ELAC + MSC groups. Conclusion: The application of MSCs to ELAC scaffolds improved biomechanical and histological outcomes when compared with direct repair for the treatment of critically sized defects of the RC in a rabbit model. Clinical Relevance: This study demonstrates the feasibility of repairing segmental tendon defects with a load-bearing, collagen biotextile in an animal model, showing the potential applicability of RC repair supplementation using allogeneic stem cells.

Background Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. Methods Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. Results Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). Discussion Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a paucity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty.Patients aged 40 to 89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores.A total of 125 patients (53 male; mean age, 69.5 ±10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24±1.9. and the Preoperative, Operative and Postoperative SDM subscale scores were -1.54±2.0, -2.59±2.2 and -2.48±2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other two subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (OR -1.03, 95% CI -2.0 - -0.1, p = 0.039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4 - -0.1, p = 0.038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score.Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations, but indicated a significant preference for surgeon-led decision-making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type or treating surgeon. Overall, patients demonstrated a predilection for a SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice.We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance.Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program's were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values0.05 were considered significant.The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study.Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought.Level III, therapeutic study.

Purpose The purpose of this study was to perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American to European shoulder surgeon preferences. Methods Nineteen surgeons from North America [NAP] and 18 surgeons from Europe [EP] agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first two rounds were used to develop a Likert style questionnaire for round 3. If agreement at round 3 was 60% for an item, the results were carried forward into round 4. For round 4 the panel members outside consensus >60%, Results There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the work up; MR imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of non-operative treatment for a minimum of 6 months. The NAP were likely to routinely prescribe NSAIDs [NA 89%; EU 35%] and consider steroids for impingement [NA 89%. EU 65%]. Conclusion Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of non-operative treatment for a minimum of 6 months. The panel also agreed that SAD is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to non-surgical measures.

» Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis. » Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint. » In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears. » The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.

Background: Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure. Purpose: To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test. Results: In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet ( P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion ( P = .047) and broken, loose, or improperly placed screws ( P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport ( P < .001), return to sport at the same level ( P < .001), incidence of subluxation ( P = .003) or positive apprehension ( P = .002), and revision surgery for recurrent instability ( P = .027). Conclusion: Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

The current opioid epidemic in the United States has become a public health crisis with an estimated 150 daily deaths and nearly 47,000 opioid-related deaths in the United States in 2017 alone. Sensible prescriber practice changes have been a focus of policymakers to decrease the total number of narcotic pain medications in circulation. In the state of Ohio, opioid prescription limits for acute pain were enacted in August 2017. However, given the association of acute opioid exposure with long-term use and lack of assessment of these policies, there is an unmet need to evaluate the effects of similar legislation in Ohio on postoperative opioid dosing after shoulder arthroplasty. This study evaluates the effects of opioid prescription-limiting legislation in Ohio on postoperative opioid dosing in shoulder arthroplasty and assesses risk factors related to long-term opioid use.All patients undergoing primary and revision shoulder arthroplasty over a 5-year period performed by a single surgeon were included. The pre-legislation (PRE) and post-legislation (POST) groups were defined as patients undergoing shoulder arthroplasty before August 31, 2017 and on or after August 31, 2017, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively. Patients were designated as opioid tolerant if they had filled an opioid prescription within 30 days of surgery. A binary logistic regression analysis was applied to assess factors related to long-term opioid use.A total of 334 patients were categorized into 2 cohorts: PRE (n = 99) and POST (n = 235). Accounting for legislative effects, we observed significant reductions in cumulative morphine milligram equivalent (MME) dosing in the opioid-naive patients in the 7-day and 30-day postoperative periods (450.0 MMEs in PRE group vs. 210.0 MMEs in POST group, P.001) and in the opioid-tolerant patients in the 7-day postoperative period (450.0 MMEs in PRE group vs. 250.0 MMEs in POST group, P = .001). Among the opioid-naive patients, the POST group had a significant MME reduction in the 90-day postoperative period relative to the PRE cohort (P.001). Preoperative opioid tolerance and benzodiazepine tolerance were independent risk factors for increased MME dosing at 90 days postoperatively (P.001 and P = .02, respectively).Opioid prescription-limiting legislation for acute pain in the state of Ohio is associated with a notable reduction in opioid MME dosing in the 90-day postoperative period after shoulder arthroplasty, particularly in opioid-naive patients in the first 30 days postoperatively. Preoperative opioid tolerance is correlated with significantly higher MME dosing postoperatively after shoulder arthroplasty.

Despite advancements in surgical techniques and materials for rotator cuff repair procedures, primary repair failures remain common. This study examines the use of electrochemically aligned collagen (ELAC) threads woven into biotextile scaffolds as grafts to repair critical infraspinatus tendon defects in New Zealand White rabbits. Three surgical treatment groups were evaluated: rabbits undergoing direct repair as operative controls, rabbits receiving ELAC scaffolds alone, and rabbits treated with mesenchymal stem cell (MSC)-seeded ELAC scaffolds. In each animal, the intact, contralateral infraspinatus served as an internal positive control. Tendon-bone constructs were harvested after 3 months in vivo and outcome measures included biomechanical testing, histological staining, and immunohistochemical staining. Biomechanical testing revealed that maximum load-bearing capacity was comparable between all groups, while MSC-seeded scaffold repairs exhibited increased stiffness relative to non-seeded scaffold repairs. Histological staining revealed robust collagen deposition around ELAC fibers and increased cellularity within the continuum of woven scaffolds as compared to native tendon. Immunohistochemical staining revealed presence of collagens I and III in all groups, but procollagen I and the tendon-specific marker tenomodulin were only observed in seeded and non-seeded ELAC scaffold repairs. Findings of this pilot study warrant continued investigation of ELAC biotextile scaffolds for repair of critically-sized rotator cuff tendon defects. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1864-1876, 2019.

BACKGROUND Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR. METHODS Adult patients undergoing arthroscopic RCR were prospectively enrolled and randomized to one of two groups. The control received our institution's standard-of-care pain protocol, including oxycodone-acetaminophen 5 to 325 mg on discharge. The ketorolac group received the standard-of-care protocol, intravenous ketorolac at the completion of the procedure, and oral ketorolac on discharge. Pain and functional outcome scores and narcotic utilization were recorded three times per day for the first 5 days after surgery. Repeat magnetic resonance imaging was done at least 6 months postoperatively. RESULTS In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7 ± 10.6 years, and 66.7% of patients were male. No differences were observed in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 versus 8.82, P < 0.001). No difference was observed in functional outcome scores at up to 6 weeks postoperatively between the two groups. No difference was observed in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. Twenty-two of 39 patients underwent repeat magnetic resonance imaging at a mean of 7.9 months postoperatively, of which 5 (22%) demonstrated a retear of their rotator cuff. No significant difference was observed between the ketorolac and control groups in the rate of retear (P = 1.00). DISCUSSION Adjunctive ketorolac substantially reduces narcotic utilization after arthroscopic RCR.

Background: Major League Baseball (MLB) adopted a rule change in 2016 to reduce the number of collisions that occur when a player slides into a base. The effect of rule 6.01(j) has not been quantified, and it remains unknown if this rule change has led to improved player safety. Hypothesis: Rule 6.01(j) would be associated with a reduction in the number of collision-related injuries at second base. Study Design: Cohort study; Level of evidence, 3. Methods: Using data from the MLB Health and Injury Tracking System, we quantified the number of collision-related injuries for defensive (ie, fielding) players in the infield at the major and minor league levels between the 2010 and 2019 seasons. We compared the median number of collision-related injuries for defensive players in the infield from before (2010-2015) to after (2016-2019) the implementation of rule 6.01(j) and also calculated the difference in location of the median from the seasons before versus after the rule change. An additional 3 analyses were performed to support or contradict a conclusion that any observed reduction in injuries at the start of the 2016 season was likely caused by the adoption of rule 6.01(j). Results: The median number of collision-related injuries for defensive players at second base decreased from 58.5 to 37.5 injuries per season after the rule change, which was a 36% decrease (difference in location, 19.5 [95% CI, 5.0 to 31.0]; P = .019). In contrast, the median number of collision-related injuries at first base decreased by only 14.1%, from 49.5 before to 42.5 after the rule change (difference in location, –9.0 [95% CI, –4.0 to 18.0]; P = .16), and the median number of collision-related injuries per season at third base was unchanged at 15 per season. Conclusion: This rule change was associated with a decrease in the number of collision-related injuries, with the largest effect observed at second base, as expected.

Background Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. Methods In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents’ prescribing practices, and methods of patient counseling regarding opioid use and disposal. Results A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient’s symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. Discussion To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

OBJECTIVES: Multiple early childhood screenings are recommended, but gaps persist in implementation. Our aim for this project was to improve screening, discussion, referral, and follow-up of development, autism spectrum disorder (ASD), maternal depression, and social determinants of health (SDoH) to 90% by July 2018. METHODS: This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes. RESULTS: Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening. CONCLUSIONS: Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.

Background Superior capsular reconstruction (SCR) addresses massive, irreparable rotator cuff tears in young patients. The purpose of this study was to retrospectively evaluate clinical outcomes and graft integrity in patients following SCR. Methods Thirty-four consecutive patients undergoing SCR by 2 surgeons with minimum 2-year follow-up were identified. Functional outcomes were obtained, including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and Single Assessment Numeric Evaluation (SANE) scores. Graft integrity was evaluated on magnetic resonance images (MRIs). Results Thirty-five shoulders in 34 patients were identified. Four patients underwent subsequent surgery. The mean preoperative scores were SST 21.6 ± 17.6, ASES 28.3 ± 10.1, SANE 50.6 ± 22.1, and VAS 6.6 ± 1.7. The mean postoperative outcomes were SST 79.1 ± 19.6, ASES 79.9 ± 17.4, SANE 74.3 ± 18.7, and VAS 1.5 ± 2.2. There was statistically significant improvement in SST, ASES, and VAS following SCR. MRI revealed graft failure in 62% (n = 13 of 21) of shoulders. Radiographic evidence of graft healing did not have any effect on SST, ASES, SANE, or VAS scores. Conclusion Given the high rate of graft failure without a significant difference in clinical outcomes, graft healing after SCR might not be an independent predictor of success. The improved clinical improvement in patients undergoing SCR may be due to other known beneficial aspects of the procedure, including partial rotator cuff repair, debridement, and biceps management.

BACKGROUND: Fatty infiltration of the rotator cuff occurs after injury to the tendon and results in a buildup of adipose in the muscle. Fatty infiltration may be a biomarker for predicting future injuries and mechanical properties after tendon repair. As such, quantifying fatty infiltration accurately could be a relevant metric for determining the success of tendon repairs. Currently, fatty infiltration is quantified by an experienced observer using the Goutallier or Fuchs staging system, but because such score-based quantification systems rely on subjective assessments, newer techniques using semiautomated analyses in CT and MRI were developed and have met with varying degrees of success. However, semiautomated analyses of CT and MRI results remain limited in cases where only a few two-dimensional slices of tissue are examined and applied to the three-dimensional (3-D) tissue structure. We propose that it is feasible to assess fatty infiltration within the 3-D volume of muscle and tendon in a semiautomated fashion by selecting anatomic features and examining descriptive metrics of intensity histograms collected from a cylinder placed within the central volume of the muscle and tendon of interest. QUESTIONS/PURPOSES: (1) Do descriptive metrics (mean and SD) of intensity histograms from microCT images correlate with the percentage of fat present in muscle after rotator cuff repair? (2) Do descriptive metrics of intensity histograms correlate with the maximum load during mechanical testing of rotator cuff repairs? METHODS: We developed a custom semiautomated program to generate intensity histograms based on user-selected anatomic features. MicroCT images were obtained from 12 adult female New Zealand White rabbits (age 8 to 12 months, weight 3.7 kg ± 5 kg) that were randomized to surgical repair or sham repair of an induced infraspinatus defect. Intensity histograms were generated from images of the operative and contralateral intact shoulder in these rabbits which were presented to the user in a random order without identifying information to minimize sources of bias. The mean and SD of the intensity histograms were calculated and compared with the total percentage of the volume threshold as fat. Patterns of fat identified were qualitatively compared with histologic samples to confirm that thresholding was detecting fat. We conducted monotonic tensile strength-to-failure tests of the humeral-infraspinatus bone-tendon-muscle complex, and evaluated associations between histogram mean and SDs and maximum load. RESULTS: The total percentage of fat was negatively correlated with the intensity histogram mean (Pearson correlation coefficient -0.92; p < 0.001) and positively with intensity histogram SD (Pearson correlation coefficient 0.88; p < 0.001), suggesting that the increase in fat leads to a reduction and wider variability in volumetric tissue density. The percentage of fat content was also negatively correlated with the maximum load during mechanical testing (Pearson correlation coefficient -78; p = 0.001), indicating that as the percentage of fat in the volume increases, the mechanical strength of the repair decreases. Furthermore, the intensity histogram mean was positively correlated with maximum load (Pearson correlation coefficient 0.77; p = 0.001) and histogram SD was negatively correlated with maximum load (Pearson correlation coefficient -0.72; p = 0.004). These correlations were strengthened by normalizing maximum load to account for animal size (Pearson correlation coefficient 0.86 and -0.9, respectively), indicating that as histogram mean decreases, the maximum load of the repair decreases and as histogram spread increases, the maximum load decreases. CONCLUSION: In this ex vivo rabbit model, a semiautomated approach to quantifying fat on microCT images was a noninvasive way of quantifying fatty infiltration associated with the strength of tendon healing. CLINICAL RELEVANCE: Histogram-derived variables may be useful as surrogate measures of repair strength after rotator cuff repair. The preclinical results presented here provide a foundation for future studies to translate this technique to patient studies and additional imaging modalities. This semiautomated method provides an accessible approach to quantification of fatty infiltration by users of varying experience and can be easily adapted to any intensity-based imaging approach. To translate this approach to clinical practice, this technique should be calibrated for MRI or conventional CT imaging and applied to patient scans. Further investigations are needed to assess the correlation of volumetric intensity histogram descriptive metrics to clinical mechanical outcomes.

Background: Superior labral anterior to posterior (SLAP) tears are one of the most common injuries to the shoulder, with the type II variant representing the most frequently encountered subtype. Purpose: To systematically review the literature to better understand outcomes after arthroscopic repair of isolated type II SLAP lesions using knotted versus knotless anchors based on implant number, implant location, patient position, and portal position. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review investigating all studies in the literature between January 2000 and June 2019 reporting on patients undergoing arthroscopic repair for isolated type II SLAP lesions using knotted versus knotless suture anchors was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the PubMed, BIOSIS Previews, SPORTDiscus, PEDro, and Embase databases. Results: A total of 234 patients undergoing isolated arthroscopic repair of type II SLAP lesions using suture anchors were identified, with 76% (179/234) treated using knotted anchors versus 24% (55/234) treated using knotless anchors. Complications were reported in 12% of patients treated using knotted anchors versus no patients treated using knotless anchors ( P = .008). The incidence of complications for knotted anchor repair was not significantly affected by patient position ( P = .22) or portal position ( P = .19). Using multiple regression analysis, we found no significant association with the incidence of complications when analyzing for anchor design ( R 2 = 0.02; P = .06) or anchor position ( R 2 = 0.02; P = .92). No significant difference in return-to-activity timing was appreciated based on anchor type ( P = .28), patient position ( P = .98), or portal position ( P = .97) in patients treated using knotted anchors. Conclusion: Patients treated using knotted anchors were significantly more likely to experience a postoperative complication compared with patients treated using knotless anchors after arthroscopic repair of isolated type II SLAP lesions. Despite the increased incidence of a postoperative complication after knotted anchor fixation compared with knotless anchor fixation, multiple regression analysis showed that anchor design and anchor position were not significantly predictive of the incidence of complications. Given the increasing popularity of knotless anchor fixation, further study on the long-term outcomes after knotless repair for isolated type II SLAP lesions is warranted.

BACKGROUND In patients on warfarin anticoagulation therapy, elective shoulder arthroplasty surgeons must carefully balance bleeding and embolic risks. Currently, an international normalized ratio (INR) threshold of 1.5 is supported in the setting of elective surgery. However, no previous study has investigated the optimal preoperative INR target specifically in shoulder arthroplasty. The purpose of this study was to evaluate the association of preoperative INR with rates of transfusion, complication, and readmission/revision surgery in shoulder arthroplasty. METHODS Patients who underwent elective shoulder arthroplasty were identified in a national database. The primary outcome of interest was the risk for all-cause complication at 30 days postoperatively. Major and minor complication, revision surgery, and readmission rates were also investigated. RESULTS From 2006 to 2016, 1,014 procedures were identified who had undergone elective shoulder arthroplasty with a perioperative INR lab result within 24 hours of surgery. In our cohort, 550 patients (54.2%) were women, with an average age of 71.0 ± 9.8 years. After controlling for confounders, patients with a preoperative INR > 1.5 were 18.9 times as likely to have a major complication as those with a preoperative INR ≤ 1.0 (P = 0.003). Patients with an INR of 1.25 < INR ≤ 1.5 did not have a statistically significant risk of minor or major complication in comparison with those with an INR ≤ 1.0 (P = 0.23, P = 0.67). DISCUSSION Although recent hip and knee arthroplasty literature has found that an INR < 1.25 may be an optimal preoperative INR goal, our results did not find an increased risk for bleeding and complication with an INR ≤ 1.5 for shoulder arthroplasty. These results support current guidelines recommending a preoperative INR ≤ 1.5 for shoulder arthroplasty.

Sokol et al1 have provided an excellent review of the current state of existing screeners for social determinants of health (SDoH). We have previously published on the correlations of parental Adverse Childhood Experiences (ACEs) and child developmental screening results,2 which illustrates an example of the inextricable links between factors in the social milieu and child health outcomes. It is believed that social determinants also create real-world barriers to families engaging in necessary services within the health care system. Given the … E-mail: rgillespie{at}childrens-clinic.com

BACKGROUND: The Latarjet procedure restores shoulder stability through reconstruction of the glenoid arc. Prior investigations of glenoid and coracoid dimensions have been underpowered to detect differences based on sex and race. QUESTIONS/PURPOSES: We sought to establish normative values for glenoid width and coracoid dimensions based on sex, race, and age. In addition, we assessed the restoration of glenoid dimensions using the classic and modified Latarjet techniques (classic technique: placing lateral surface of the coracoid to the glenoid; modified technique: placing inferior surface of the coracoid to the glenoid). METHODS: A total of 993 cadaveric specimens (n = 1986 scapulae) from people over 18 years of age at the time of death were analyzed. Measurements of maximal glenoid width, coracoid width, thickness, and length were recorded. Statistical analysis was performed to detect differences based on sex and race, while univariable linear regression was used to determine the association of increasing age on measured dimensions. RESULTS: All dimensions of specimens were significantly larger in males than in females. Caucasians possessed larger mean glenoid width, coracoid width, and coracoid length, while coracoid thickness was significantly larger in African Americans. Linear regression analysis found that increasing age was associated with increased glenoid width and coracoid dimensions. Coracoid positioning restored glenoid width in defects measuring 20% of glenoid width using both classic and modified Latarjet techniques, while defects measuring up to 25% were more accurately reproduced using the modified technique. CONCLUSION: Dimensions were significantly larger in males and in Caucasians, aside from coracoid thickness. Mean dimensions increased with advancing age. Coracoid positioning using classic or modified Latarjet techniques restored glenoid width defects measuring 20% of the glenoid width, while the modified technique allowed for restoration of larger defects. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-018-9618-4) contains supplementary material, which is available to authorized users.

Objectives: Arthroscopic rotator cuff repairs are associated with substantial postoperative pain. Traditionally, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents are associated with several side effects and a significant potential for abuse. This study evaluates the efficacy of ketorolac, a non-steroidal anti-inflammatory drug with analgesic properties, as an adjunctive agent for postoperative pain control following arthroscopic rotator cuff repair. Methods: Adult patients undergoing an arthroscopic rotator cuff repair were prospectively enrolled. Patients who met inclusion and exclusion criteria were randomized into one of two groups. The control group received our standard of care pain protocol, including oxycodone-acetaminophen 5-325 on discharge. Patients in the ketorolac group additionally received a dose of IV ketorolac intraoperatively and were prescribed a scheduled dose of oral ketorolac (10mg by mouth every six hours for three days) along with omeprazole (20mg by mouth every day for three days) for acid reflux. Visual Analogue Scale (VAS), functional outcome scores, and total narcotic utilization were recorded three times per day for the first five days after surgery. Statistically significant differences in patient demographics and comorbidities between groups were determined initially with univariate analysis. Linear mixed-effect models were then fitted for each outcome variable to evaluate the main effects of treatment group and follow-up times. Results: In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7±10.6 years and 66.7% of patients were male. There were no differences in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. (Table 1) Patients in the Ketorolac group had lower mean VAS scores and opioid utilization at all time points. (Figure 1, 2) On multivariate analysis that controls for confounding variables, patients in the ketorolac group had a mean 9.67 decrease in VAS scores in comparison to the control group, though these results were not statistically or clinically significant (Coefficient estimate= -9.67, 95% CI -25.13-5.79, p=.2202; MCID 13). (Table 3) Patients in the ketorolac group utilized significantly less narcotics, with a mean of 0.7 fewer pills of oxycodone-acetaminophen per time interval in comparison to the control group (Coefficient estimate=-0.70, 95% CI -1.005 -0.389, pConclusions: In this prospective, randomized, controlled study, the use of adjunctive intravenous and short-term oral ketorolac substantially reduced narcotic utilization following arthroscopic rotator cuff repair.

To determine the feasibility and provider acceptability of implementing assessments for parental ACEs within the context of an outpatient pediatric clinic, and to compare parental ACE detection rates between an item-level response tool and an aggregate-level response tool. A convenience sample of parents completed one of two assessment tools during their child’s four month well visit. Detection of ACE scores ≥4 was compared between the two tools. Providers conducting the assessments completed a qualitative survey describing their experiences. Detection rates were significantly higher with the use of an aggregate-level reporting tool compared to item-level tool (11.2% versus 8.1%, p = 0.013). Provider feedback on the assessment process was positive; providers reported improved clinic visits without undue burden in terms of time constraints or parental resistance to ACE assessments. Implementing parental ACE assessments is feasible with limited resources in an outpatient setting. Providers and parents appear receptive to the conversations about past trauma, and find value in including this information in their counseling during well visits. Parents appear to be more likely to disclose ACEs when a degree of privacy is given through aggregate-level versus item-level reporting.

Addressing adverse childhood experiences (ACEs) in primary care pediatric practice is riddled with potential pitfalls that prevent most providers from implementing ACE or toxic stress screening in their practices. However, the growing body of literature and clinician experience about ACE screening shows how this practice is also ripe with possibilities beyond just the treatment of trauma-related diagnoses and for the prevention of intergenerational transmission of toxic stress. This article reviews the current state of screening for ACEs and toxic stress in practice, describes how pediatricians and clinics have overcome pitfalls during implementation of practice-based screening initiatives, and discusses possibilities for the future of primary care-based screening. [ Pediatr Ann. 2019;48(7):e257–e261.]

INTRODUCTION Participation of women in medicine has increased markedly in recent decades, but gender disparities still exist, particularly in academic medicine. To provide insight into the gender gap, specifically in academic orthopaedic sports medicine, we investigated the relationship between gender and authorship in orthopaedic sports literature from 1972 to 2018. METHODS Information about every original article in four prominent orthopaedic sports medicine journals between 1972 and 2018 was extracted from PubMed. The proportions of female first, second, middle, and senior authors over time were determined. Gender influences on level of evidence, academic degrees, and academic productivity and longevity were also studied. Student t-test, multiple linear regression, chi-square test, Cochran-Armitage trend test, and Kaplan-Meier analysis were used to determine significance between groups. RESULTS In our sample, 16.6% of all authors were female. The proportion of female authors increased from 2.6% (1972 to 1979) to 14.7% (2010 to 2018). Female authors averaged fewer publications (1.9 versus 2.8 articles for male authors) and were more likely to be attributed middle authorship (45.9% versus 37.1%) than senior authorship (14.7% versus 22.1%, P < 0.001). Female authors were more likely to be full-time research staff, such as a PhD (18.2% versus 9.0%, P < 0.001), which correlated with a higher level of evidence (B = -0.162, P < 0.001). Gender differences in academic longevity decreased over decades (1972 to 1989, 1990 to 1999, 2000 to 2008), demonstrated by decreasing significance of Kaplan-Meier log-rank tests (

Objective To determine whether maternal and paternal exposure to adverse childhood experiences (ACEs) has an association with offspring healthcare use by 2 years of age. Study design A retrospective cohort study was performed on 454 patients at a large suburban pediatric primary care practice whose mother (n = 374) or father (n = 156) or both (n = 123) completed an ACE survey between October 2012 and June 2014. The association between self-reported parental ACEs and healthcare use by 2 years of age, including number of missed well-child visits, sick visits, and delayed or missed immunizations, was modeled using multivariable negative binomial regression. All analyses adjusted for child sex, payer source, and preterm birth. Results Maternal, but not paternal, ACE exposure was significantly associated with missed well-child visits by 2 years of age. For each additional maternal ACE, there was a significant 12% increase in the incidence rate of missed well-child visits (relative risk, 1.12; 95% CI, 1.03-1.22; P = .010). Maternal and paternal ACE scores were not significantly associated with increased sick visits or delayed or missed immunizations. Conclusions The ACE exposure of mothers is negatively associated with adherence to preventive healthcare visits among their children early in life. Future research is needed to elucidate the mechanisms of this association and to develop and implement family-based intervention strategies.

Introduction Postdischarge management for shoulder replacement continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. The goal of this study was to develop a nomogram to preoperatively predict a patient's discharge disposition after elective shoulder arthroplasty. Methods Patients who underwent elective shoulder arthroplasty between 2012 and 2015 were identified in the National Surgical Quality Improvement Program database. A multivariable logistic regression model was used to identify risk factors for discharge to a postacute care facility, and these results were used to create a predictive nomogram. Results From 2012 to 2015, 8,363 procedures were identified. In our cohort, 962 patients (11.5%) were discharged to a postacute care facility, and 7,492 patients (88.5%) were discharged home. Preoperative functional status, followed by American Society of Anesthesiologists Class and age, had the strongest predictive value for discharge disposition after shoulder arthroplasty. Discussion Discharge disposition can be predicted using a nomogram with commonly identified preoperative and intraoperative variables. Level of evidence Level III, retrospective cohort design, observational study.

Background A surgical learning period may be quantified after which operative duration is significantly reduced. We sought to retrospectively quantify and compare surgeon’s learning experience for total shoulder arthroplasty and reverse shoulder arthroplasty. Methods We reviewed 2055 shoulder arthroplasty cases from 2011 to 2015 for four early-career and four later-career fellowship-trained shoulder surgeons from four institutions. We plotted consecutive case number versus operative time for each surgeon separately for total shoulder arthroplasty or reverse shoulder arthroplasty. Two-step regression approach was used to determine a plateau point or end of the learning period. Additionally, the mean annual volume of reverse shoulder arthroplasty and total shoulder arthroplasty for each surgeon was plotted against mean surgery duration. Early- and later-career surgeons were compared with regression analysis. Results Early-career surgeons demonstrated a significant decrease in operative time with increasing annual case volume for reverse shoulder arthroplasty ( p = 0.01; m = −1.1) and total shoulder arthroplasty ( p = 0.02; m = −0.8). Three of four early-career surgeons reached a plateau point for either reverse shoulder arthroplasty or total shoulder arthroplasty between 12 and 86 cases. Conclusion For only early-career surgeons, higher case volume yields decreased operative duration, with improvement more pronounced for reverse shoulder arthroplasty compared to total shoulder arthroplasty. Though the learning period varies, it may be fewer than 90 cases.

Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty.A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted.The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P.001). There were no transfusion requirements or postoperative complications noted in either group.In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.

OBJECTIVES: The study objective was to determine if maternal and paternal exposure to adverse childhood experiences (ACEs) have a significant association with negative offspring development at 24 months of age in a suburban pediatric primary care population. METHODS: A retrospective cohort study was conducted of 311 mother-child and 122 father-child dyads who attended a large pediatric primary care practice. Children were born from October 2012 to June 2014, and data were collected at the 2-, 4-, and 24-month well-child visits. Multivariable Poisson regression with robust error variance was used to model the relationship between self-reported parental ACEs and the outcomes of suspected developmental delay at 24 months and eligibility for early intervention services. RESULTS: For each additional maternal ACE, there was an 18% increase in the risk for a suspected developmental delay (relative risk: 1.18, 95% confidence interval: 1.08–1.29). A similar trend was observed for paternal ACEs (relative risk: 1.34, 95% confidence interval: 1.07–1.67). Three or more maternal ACEs (versus CONCLUSIONS: Parental ACE exposures can negatively impact child development in multiple domains, including problem solving, communication, personal-social, and motor skills. Research is needed to elucidate the psychosocial and biological mechanisms of intergenerational risk. This research has implications for the value of parental ACE screening in the context of pediatric primary care.

Background Currently, there are no well-established suture protocols to attach fully load-bearing scaffolds which span tendon defects between bone and muscle for repair of critical sized tendon tears. Methods to attach load-bearing tissue repair scaffolds could enable functional repair of tendon injuries. Methods Sixteen rabbit shoulders were dissected (New Zealand white rabbits, 1 yr. old, female) to isolate the humeral–infraspinatus muscle complex. A unique suture technique was developed to allow for a 5 mm segmental defect in infraspinatus tendon to be replaced with a mechanically strong bioscaffold woven from pure collagen threads. The suturing pattern resulted in a fully load-bearing scaffold. The tensile stiffness and strength of scaffold repair were compared with intact infraspinatus and regular direct repair. Findings The failure load and displacement at failure of the scaffold repair group were 59.9 N (standard deviation, SD = 10.7) and 10.3 mm (SD = 2.9), respectively and matched those obtained by direct repair group which were 57.5 N (SD = 15.3) and 8.6 mm (SD = 1.5), ( p > 0.05). Failure load, displacement at failure and stiffness of both of the repair groups were half of the intact infraspinatus shoulder group. Interpretation With the developed suture technique, scaffold repair showed similar failure load, displacement at failure and stiffness to the direct repair. This novel suturing pattern and the mechanical robustness of the scaffold at time zero indicates that the proposed model is mechanically viable for future in vivo studies which has a higher potential to translate into clinical uses.

The incidence of failed rotator cuff repairs remains high, especially in the setting of massive tears or revision repairs. The purpose of this study was to evaluate patient outcomes and repair integrity after augmentation with the repair patch, a poly-l-lactide synthetic polymer.Sixteen consecutive patients with massive or recurrent rotator cuff tears underwent open repair with synthetic poly-l-lactide patch augmentation. Two patients required the patch to bridge defects, and 1 patient retore after a motor vehicle accident and had revision surgery at another institution. The 13 remaining patients were retrospectively evaluated from 1.2 to 1.7 years (average, 1.5 years) after surgery by PENN, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation scores. Magnetic resonance imaging was used to examine the integrity of the repair at a minimum of 1 year of follow-up.The mean age was 57.3 years (42-68 years). Five patients (38%) had an intact rotator cuff at the time of follow-up. The remaining patients (62%) had full-thickness tears. PENN scores significantly improved from a preoperative score of 50.9 to 77.6 (P.005). American Shoulder and Elbow Surgeons scores significantly improved from 32.8 to 74.2 (P = .0001). Single Assessment Numeric Evaluation scores at latest follow-up were 76.2.Poly-l-lactide repair patch augmentation of massive and recurrent large to massive rotator cuff tears demonstrates significant improvement in shoulder outcome measures for this difficult population, despite a retear rate of 62%. Further investigation with larger, prospective long-term studies is needed to determine whether this technique provides a true benefit compared with traditional, nonaugmented repair.

Flexor tendon lacerations are traditionally repaired by using non-absorbable monofilament sutures. Recent investigations have explored to improve the healing process by growth factor delivery from the sutures. However, it is difficult to conjugate growth factors to nylon or other synthetic sutures. This study explores the performance of a novel electrochemically aligned collagen suture in a flexor tendon repair model with and without platelet derived growth factor following complete tendon laceration in vivo. Collagen suture was fabricated via electrochemical alignment process. Heparin was covalently bound to electrochemically aligned collagen sutures (ELAS) to facilitate affinity bound delivery of platelet-derived growth factor-BB (PDGF-BB). Complete laceration of the flexor digitorum profundus in the third digit of the foot was performed in 36 skeletally mature White Leghorn chickens. The left foot was used as the positive control. Animals were randomly divided into three groups: control specimens treated with standard nylon suture (n=12), specimens repaired with heparinated ELAS suture without PDGF-BB (n=12) and specimens repaired with heparinated ELAS suture with affinity bound PDGF-BB (n=12). Specimens were harvested at either 4weeks or 12weeks following tendon repair. Differences between groups were evaluated by the degree of gross tendon excursion, failure load/stress, stiffness/modulus, absorbed energy at failure, elongation/strain at failure. Quantitative histological scoring was performed to assess cellularity and vascularity. Closed flexion angle measurements demonstrated no significant differences in tendon excursion between the study groups at 4 or 12weeks. Biomechanical testing showed that the group treated with PDGF-BB bound heparinated ELAS suture had significantly higher stiffness and failure load (p0.05) at 12-weeks relative to both heparinated ELAS suture and nylon suture. Similarly, the group treated with PDGF-BB bound suture had significantly higher ultimate tensile strength and Young's modulus (p0.05) at 12-weeks relative to both ELAS suture and nylon suture. Compared to nylon controls, heparinized ELAS with PDGF-BB improved biomechanics and vascularity during tendon healing by 12-weeks following primary repair. The ability of ELAS to deliver PDGF-BB to the lacerated area of tendon presents investigators with a functional bioinductive platform to improve repair outcomes following flexor tendon repair.A high strength aligned collagen suture was fabricated via linear electrocompaction and heparinized for prolonged delivery of PDFG-BB. When it was used to suture a complete lacerated flexor tendon in a chicken model controlled release of the PDGF-BB improved the strength of treated tendon after 12 weeks compared to tendon sutured with commercial nylon suture. Furthermore, Collagen suture with affinity bound PDGF-BB enhanced the vascularization and remodeling of lacerated tendon when it compare to synthetic nylon suture. Overall, electrocompacted collagen sutures holds potential to improve repair outcome in flexor tendon surgeries by improving repair strength and stiffness, vascularity, and remodeling via sustained delivery of the PDGF-BB. The bioinductive collagen suture introduces a platform for sustained delivery of other growth factors for a wide-array of applications.

Rotator cuff injuries are common in both young and elderly patients. Despite improvements in instrumentation and surgical techniques, the failure rates following tendon reconstruction remain unacceptably high. To improve outcomes, graft patches have been developed to provide mechanical strength and to furnish a scaffold for biologic growth across the delicate tendon-bone junction. Although no patch effectively re-creates the structured, highly organized system of prenatal tendon development, augmenting rotator cuff repair may help restore native tendon-to-bone attachment while reproducing the mechanical and biologic properties of native tendon. An understanding of biologically and synthetically derived grafts, along with knowledge of the preliminary data available regarding their combined use with growth factors and stem cells, is needed to improve management and treatment outcomes. The current literature has not been consistent in showing patch augmentation to be beneficial over traditional repair, but novel scaffolding materials may help facilitate rotator cuff tendon repair that is histologically and biomechanically comparable to native tendon.