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This article reviews techniques and outcomes of surgical fixation for distal clavicle fractures. Near 100% union has been reported for several techniques. The most common are locked plating, coracoclavicular fixation and a combination of plating with CC fixation. Hook plates are useful for particular fracture patterns, but there can be complications specific to this implant. Low-profile constructs are favored due to the high rates of symptomatic hardware. Fixation of subacute and chronic injuries can provide reliable functional improvements, but is inferior to acute fixation. Surgery is generally the treatment of choice for displaced fractures in athletes. [ABSTRACT FROM AUTHOR]

Reverse shoulder arthroplasty (RSA) has been shown to reliably improve pain and functional outcomes for multiple pathologies. Despite its increasing use in the United States since its introduction in 2004, few studies have investigated long-term outcomes of this procedure. This information is vital in many ways, including durability of functional outcomes, complication profiles, and implant survivorship. Our prospectively collected shoulder arthroplasty registry included 471 patients who had undergone RSA prior to December 31, 2010, by a single surgeon at a high-volume shoulder arthroplasty center. The study sample included 94 patients with a minimum of 10 years' follow-up, and we evaluated the indications for RSA, complications, pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction on these patients at baseline, 2-5 years, and 10 or more years of follow-up. Prosthesis survivorship was determined by Kaplan-Meier survival analysis performed with revision for any reason as the end point for all 471 patients in the study period regardless of follow-up interval. The 93 patients with at least 10 years of follow-up were 63% female (60) and 37% male (34), with an average age of 66±10 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs. Patient-reported outcome measures at 10 years or more included a current pain rating averaging 2±3 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73±28. There was no deterioration in function or pain from midterm to long-term follow-up, as the SANE and pain score changed by less than the minimal clinically important difference or improved in 87% and 90% of patients, respectively. Overall, patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied. For the subset of 68 patients who were contacted for follow-up, 64 (94%) would have the procedure again and 4 (6%) would not. Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% (95% confidence interval [CI] 84%-92%) at 5 years and 81% (95% CI 74%-86%) at 10 years. This study presents the largest American cohort of Grammont design RSA at a minimum 10-year follow-up. Although RSA provided clinically significant and durable improvements in pain and function, the complication and revision rates were higher than prior reports. Despite this, the vast majority of patients were satisfied and would have the procedure again. [ABSTRACT FROM AUTHOR]

The contemporary literature suggests that a primary feature of recurrence of rotator cuff tear after arthroscopic repair is failure of tendon healing, which can occur for multiple reasons, including compromised tissue quality. Recently, the use of augmentation implants, grafts, or scaffolds has emerged as a strategy to address the issue of deficient rotator cuff tissue. A resorbable bio-inductive collagen implant (REGENETEN; Smith & Nephew, Andover, MA) has been shown to increase tendon thickness when applied in rotator cuff repair. This article presents an experienced surgeon's tips for implanting this device. In addition, we review the current literature about this bio-inductive implant. [Display omitted] [ABSTRACT FROM AUTHOR]

Treatment of primary osteoarthritis with glenoid dysplasia or Walch type C glenoids remains controversial. There is scant literature available on patient outcomes after anatomic shoulder arthroplasty in patients with Walch type C glenoids. The purpose of this study was to evaluate the outcomes of total shoulder arthroplasty (TSA) for Walch type C dysplastic glenoids with standard (nonaugmented) glenoid components compared with TSA for glenoids with concentric wear and minimal erosion (Walch type A1). We hypothesized that TSA performed for Walch type C dysplastic glenoids with standard glenoid components can reliably produce successful results at short- to midterm follow-up. We identified all patients who had primary anatomic TSA performed for osteoarthritis in a prospective shoulder arthroplasty registry collected from 2004 to the present time. Twenty-nine patients met inclusion criteria of a preoperative Walch type C dysplastic glenoid, treatment with TSA using standard (nonaugmented) glenoid components, and a minimum of 2-year clinical follow-up. A matched cohort of 58 patients with a type A1 glenoid and minimum of 2-year clinical follow-up for anatomic shoulder arthroplasty served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), patient satisfaction, complications, and revisions were evaluated in both cohorts. The mean follow-up for this study was 4.5 years (standard deviation, 2.6 years; range, 2-10 years). Baseline measures were not significantly different between the Walch type C dysplastic group and the matched type A1 cohort (all P >.05). Both groups showed significant improvements in ASES, ASES pain, and SANE scores from baseline to the final follow-up (all P <.001). The Walch type C group had no significant differences in ASES score (P =.118), ASES pain (P =.730), or SANE score (P =.168) compared with the matched type A1 cohort. The complication rate of patients with a type C glenoid was 14% (4 of 29) with a 7% (2 of 29) revision rate. Similarly, the complication rate for the A1 matched cohort was 17% (10 of 58) with a 12% (7 of 58) revision rate. Both groups had high patient satisfaction without statistical differences (P =.549). In addition, there were no differences in the rate of radiographic lucencies or Lazarus scores (P =.222). Anatomic TSA reliably produced clinically significant improvements in pain and function and similar short- to midterm outcomes in patients with Walch type C dysplastic glenoids compared with patients with type A1 glenoids. Anatomic TSA with standard (nonaugmented) glenoid components should remain an option in patients with Walch type C dysplastic glenoids despite emerging treatment options including augmented glenoid components and reverse TSA. [ABSTRACT FROM AUTHOR]

Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room–mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs). Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups. A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P =.53) and the average staff count (P =.16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (β = –0.583, P <.001) along with surgical time and particulates with a diameter ≥ 5 μm. Staff count and particulates with a diameter < 5 μm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients. This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding—specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Glenoid component malpositioning and glenoid component retroversion have been associated with higher rates of radiolucencies, raising concerns about its implications on glenoid loosening and ultimate failure of anatomic total shoulder arthroplasty (TSA). Although there is literature regarding the relative advantages of techniques to address posterior glenoid bone loss, we are not aware of studies comparing outcomes of TSA on these challenging Walch type B2 glenoids vs. more common A1 glenoids. The purpose of this study is to compare outcomes of TSA performed on A1 glenoids and B2 glenoids treated with asymmetric glenoid reaming. We identified 1045 shoulders that had primary TSAs performed for osteoarthritis in a prospective shoulder arthroplasty registry. Two hundred eighty-nine shoulders met inclusion criteria of a preoperative Walch type A1 (178) or B2 (111) glenoid morphology, treatment with TSA, asymmetric reaming in the B2 group, and a minimum of 2-year clinical and radiographic follow-up. Postoperative radiographs were assessed for lucencies, and patient-reported outcome measures were collected at all follow-up visits. Follow-up averaged 40 ± 15 months for all patients, and more men presented with a B2 glenoid (80 of 111; 72%) compared with A1 (101 of 178; 57%) (P =.009). Age at surgery (P =.166), dominant-sided surgery (P =.281), body mass index (P =.501), smoking (P =.155), preoperative opioid use (P =.154), and diabetes (P =.331) were not significantly different between groups. Both groups had similar Constant Strength scores preoperatively (A1: 4.7 ± 7.1, and B2: 4.3 ± 7.3) but the B2 group improved significantly more at final follow-up (A1: 10.3 ± 6.2 vs. B2: 12.7 ± 6.7, P =.005). The Total Constant score was also significantly better at follow-up in the B2 glenoid group (P =.039). All other Constant subscales, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) measures showed significant improvement preoperatively to final follow-up (all P <.001) but there were no significant differences between the A1 and B2 glenoid groups (all P >.05). A similar proportion of patients rated their satisfaction as either very satisfied or satisfied between the A1 (160; 90%) and B2 (100; 90%) (P =.613). Lazarus scores were also similar between the A1 and B2 groups (P =.952) as were the rates of humeral radiolucent lines (P =.749) and humeral osteolysis (P =.507). Although patients with B2 glenoids may present a more technically challenging anatomic total shoulder arthroplasty, treatment with concurrent asymmetric glenoid reaming produced similar, successful clinical and radiographic early to midterm outcomes for patients undergoing TSA compared with A1 glenoids. Additional follow-up on this cohort will be important to confirm the durability of these early results. [ABSTRACT FROM AUTHOR]

Symptomatic subscapularis (SC) failure after anatomic total shoulder arthroplasty (TSA) is difficult to treat. The purpose of this study was to determine the outcomes of reoperation for SC failure. All patients undergoing reoperation for SC failure after TSA were identified from a single-institution database. Patients underwent either revision SC repair or revision to reverse shoulder arthroplasty. At a minimum of 1 year after reoperation, complications, reoperations, and functional outcomes were collected. Patients who initially underwent SC repair were significantly younger than patients who underwent revision to reverse shoulder arthroplasty (mean age, 59.3 years vs. 70.3 years; P =.004), had a better comorbidity profile (mean Charlson Comorbidity Index, 2.2 vs. 3.6; P =.04), and had a more acute presentation (mean time between injury and surgery, 9.1 weeks vs. 28.5 weeks; P =.03). Patients who underwent SC repair also had a significantly higher reoperation rate (52.9% vs. 0.0%, P =.01). At final follow-up, functional outcomes scores and patient satisfaction rates were not significantly different between treatment groups. Decision making on how to treat patients with SC failure following TSA remains challenging and should be individualized to the patient's age, level of activity, comorbidities, timing and mechanism of SC failure, and functional expectations. [ABSTRACT FROM AUTHOR]

Many surgeons are concerned about reports of increased complications, worse outcomes, and early failures in patients undergoing anatomic total shoulder arthroplasty after coracoid transfer. The purpose of this study was to evaluate minimum 2-year outcomes following anatomic total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure and compare them with a matched cohort of patients undergoing total shoulder arthroplasty for primary osteoarthritis. We identified 11 primary anatomic total shoulder arthroplasties performed by a single surgeon for instability arthropathy with a prior coracoid transfer procedure with a minimum of 2 years' follow-up (mean, 58 ± 35 months). A matched cohort of 33 patients with a total shoulder arthroplasty for primary osteoarthritis served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, patient satisfaction, complications, and revisions were evaluated in both cohorts. The coracoid transfer cohort showed no difference in the final ASES score (88 vs. 82, P =.166) or SANE score (85 vs. 67, P =.120) vs. the matched cohort. The postoperative ASES pain score (45 vs. 41, P =.004) was higher in the coracoid transfer cohort, but the mean improvement from preoperative to postoperative values for the ASES score (P =.954), ASES pain score (P =.183), and SANE score (P =.293) was no different between cohorts. Both cohorts had high patient satisfaction without a statistically significant difference (P =.784). At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. Longer follow-up and larger patient cohorts will provide further insights and highlight any potential differences in outcomes or revision rates. [ABSTRACT FROM AUTHOR]

Background The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option. Methods We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years' follow-up after revision surgery for functional outcome scores, reoperations, and implant survival. Results The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation. Conclusions Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff. [ABSTRACT FROM AUTHOR]

Background Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center. Methods An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA. Results A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications. Conclusion Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups. [ABSTRACT FROM AUTHOR]

Gas-loaded nanobubbles have potential as a method of oxygen delivery to increase tumour oxygenation and therapeutically alleviate tumour hypoxia. However, the mechanism(s) whereby oxygen-loaded nanobubbles increase tumour oxygenation are unknown; with their calculated oxygen-carrying capacity being insufficient to explain this effect. Intra-tumoural hypoxia is a prime therapeutic target, at least partly due to hypoxia-dependent stimulation of the formation and function of bone-resorbing osteoclasts which establish metastatic cells in bone. This study aims to investigate potential mechanism(s) of oxygen delivery and in particular the possible use of oxygen-loaded nanobubbles in preventing bone metastasis via effects on osteoclasts. Lecithin-based nanobubbles preferentially interacted with phagocytic cells (monocytes, osteoclasts) via a combination of lipid transfer, clathrin-dependent endocytosis and phagocytosis. This interaction caused general suppression of osteoclast differentiation via inhibition of cell fusion. Additionally, repeat exposure to oxygen-loaded nanobubbles inhibited osteoclast formation to a greater extent than nitrogen-loaded nanobubbles. This gas-dependent effect was driven by differential effects on the fusion of mononuclear precursor cells to form pre-osteoclasts, partly due to elevated potentiation of RANKL-induced ROS by nitrogen-loaded nanobubbles. Our findings suggest that oxygen-loaded nanobubbles could represent a promising therapeutic strategy for cancer therapy; reducing osteoclast formation and therefore bone metastasis via preferential interaction with monocytes/macrophages within the tumour and bone microenvironment, in addition to known effects of directly improving tumour oxygenation. [ABSTRACT FROM AUTHOR]