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BACKGROUND: Reliably recognizing the overall pattern and specific characteristics of proximal humerus fractures may aid in surgical decision-making. With conventional onscreen imaging modalities, there is considerable and undesired interobserver variability, even when observers receive training in the application of the classification systems used. It is unclear whether three-dimensional (3D) models, which now can be fabricated with desktop printers at relatively little cost, can decrease interobserver variability in fracture classification. QUESTIONS/PURPOSES: Do 3D-printed handheld models of proximal humerus fractures improve agreement among residents and attending surgeons regarding (1) specific fracture characteristics and (2) patterns according to the Neer and Hertel classification systems? METHODS: Plain radiographs, as well as two-dimensional (2D) and 3D CT images, were collected from 20 patients (aged 18 years or older) who sustained a three-part or four-part proximal humerus fracture treated at a Level I trauma center between 2015 and 2019. The included images were chosen to comprise images from patients whose fractures were considered as difficult-to-classify, displaced fractures. Consequently, the images were assessed for eight fracture characteristics and categorized according to the Neer and Hertel classifications by four orthopaedic residents and four attending orthopaedic surgeons during two separate sessions. In the first session, the assessment was performed with conventional onscreen imaging (radiographs and 2D and 3D CT images). In the second session, 3D-printed handheld models were used for assessment, while onscreen imaging was also available. Although proximal humerus classifications such as the Neer classification have, in the past, been shown to have low interobserver reliability, we theorized that by receiving direct tactile and visual feedback from 3D-printed handheld fracture models, clinicians would be able to recognize the complex 3D aspects of classification systems reliably. Interobserver agreement was determined with the multirater Fleiss kappa and scored according to the categorical rating by Landis and Koch. To determine whether there was a difference between the two sessions, we calculated the delta (difference in the) kappa value with 95% confidence intervals and a two-tailed p value. Post hoc power analysis revealed that with the current sample size, a delta kappa value of 0.40 could be detected with 80% power at alpha = 0.05. RESULTS: Using 3D-printed models in addition to conventional imaging did not improve interobserver agreement of the following fracture characteristics: more than 2 mm medial hinge displacement, more than 8 mm metaphyseal extension, surgical neck fracture, anatomic neck fracture, displacement of the humeral head, more than 10 mm lesser tuberosity displacement, and more than 10 mm greater tuberosity displacement. Agreement regarding the presence of a humeral head–splitting fracture was improved but only to a level that was insufficient for clinical or scientific use (fair to substantial, delta kappa = 0.33 [95% CI 0.02 to 0.64]). Assessing 3D-printed handheld models adjunct to onscreen conventional imaging did not improve the interobserver agreement for pattern recognition according to Neer (delta kappa = 0.02 [95% CI -0.11 to 0.07]) and Hertel (delta kappa = 0.01 [95% CI -0.11 to 0.08]). There were no differences between residents and attending surgeons in terms of whether 3D models helped them classify the fractures, but there were few differences to identify fracture characteristics. However, none of the identified differences improved to almost perfect agreement (kappa value above 0.80), so even those few differences are unlikely to be clinically useful. CONCLUSION: Using 3D-printed handheld fracture models in addition to conventional onscreen imaging of three-part and four-part proximal humerus fractures does not improve agreement among residents and attending surgeons on specific fracture characteristics and patterns. Therefore, we do not recommend that clinicians expend the time and costs needed to create these models if the goal is to classify or describe patients’ fracture characteristics or pattern, since doing so is unlikely to improve clinicians’ abilities to select treatment or estimate prognosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

There has been increasing interest in the use of stemless humeral implants for total shoulder arthroplasty when compared with both short-stem (SS) and standard-length implants. Although evidence for decreased surgical time and blood loss exists for stemless versus standard-length stems, far less literature exists comparing these clinical parameters for stemless versus SS implants.A retrospective review of consecutive anatomic total shoulder arthroplasty (aTSA) cases conducted by a single, fellowship-trained shoulder surgeon was undertaken from January 2016 through January 2022 with the exception of March 2020 through January 2021 secondary to the COVID-19 pandemic. Demographic patient and surgical data, including age, sex, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder arthroscopy, surgical time, use of a Hemovac drain and/or tranexamic acid, hospital length of stay (LOS), and both postoperative day #1 (POD 1) and discharge visual analog scores. The use of a stemless or SS implant was recorded. Intraoperative total blood volume loss (TBVL) was calculated, in addition to the need for either intraoperative or postoperative transfusions. Nonparametric analysis of covariance was used to examine effects of stemless versus SS aTSA on surgical time and intraoperative TBVL adjusted for demographic, clinical, and surgical variables.There were 47 SS and 83 stemless anatomic implants included, of which 74 patients (57%) overall were women. The median surgical time for the stemless cohort was 111 minutes (IQR 96-130) versus 137 minutes (IQR 113-169) for the SS cohort (P0.00001). The median intraoperative TBVL for the stemless cohort was 298.3 mL (IQR 212.6-402.8) versus 359.7 mL (IQR 253.9-415.0) for the SS cohort (P = 0.05). After multivariable regression analysis, use of stemless humeral implants was independently associated with both decreased surgical time and intraoperative blood loss (P0.001 and P = 0.005, respectively). There was a shorter median hospital LOS in the stemless group (2 days [IQR 1-2] versus 2 days [IQR 2-3], P = 0.03). The visual analog score pain score at discharge was lower among the stemless cohort (0 [IQR 0-3] versus 4 [IQR 2-6], P0.00001). Increased surgical time was associated with intraoperative TBVL (r = 0.340, P0.0001).Stemless aTSA is associated with a markedly decreased surgical time and intraoperative TBVL when compared with a SS aTSA. Furthermore, the use of a stemless implant results in a shorter hospital LOS and lower discharge pain scores.

Short-term cancellation of elective ambulatory orthopaedic surgery can result in disruption to the process flow of the operating room, with resultant negative financial implications for the health system. The risk factors for patient-related short-term cancellations within 24 hours of the surgical date have not been well defined.A retrospective review of a single orthopaedic surgery electronic internal database was done to identify all cancellations from January 1, 2016, through December 31, 2019, which were made within 24 hours of the surgical date. Inclusion criteria included elective arthroscopic procedures canceled solely for patient-related issues. Any cancellation for surgeon-related or ambulatory center-related reasons was excluded. Demographic patient and surgical data, including insurance type, employment status, previous history of cancellation for the same surgery, socioeconomic status based on the Area Deprivation Index, and surgery type, were tabulated. Each cancellation was matched 1:2 with noncanceled cases based on the anatomic site of the arthroscopy scheduled. Multivariable logistic regression was used to examine associations of patient demographic and medical characteristics with surgical cancellation.There were 4,715 total arthroscopic procedures done during the study period, of which 126 (2.7%) were canceled within 24 hours of the surgery date. The mean age of the canceled cases was 44.9 ± 16.1 years (range, 14 to 77 years), with 46 females (43%) included. The presence of MRI of the involved joint within 6 months of surgery (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17 to 0.91) and current employment (aOR, 0.56, 95% CI, 0.33-0.94) were independently predictive of noncancellation. Current smokers were more likely to cancel within 24 hours of surgery (aOR, 2.63, 95% CI, 1.4-4.9). Finally, having previously canceled the same surgery was significantly associated with a current surgical cancellation (P = 0.004).Identification of the factors associated with short-term patient-related cancellation of elective arthroscopy may serve as the basis for preoperative interventions aimed specifically at those more likely to cancel. In turn, these interventions can minimize preventable cancellations.

BACKGROUND: Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. QUESTIONS/PURPOSES: (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. METHODS: In an institutional review board–approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. RESULTS: The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. CONCLUSION: Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. LEVEL OF EVIDENCE: Level IV, therapeutic study.

INTRODUCTION Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain, although the diagnostic utility of this imaging modality is unclear. Despite this, patients often prefer to obtain radiographs and may associate them with a more satisfactory visit. METHODS New patients presenting with atraumatic shoulder pain were provided with information regarding the potential advantages and disadvantages of plain radiographs as part of their visit. Patients then decided whether to receive radiographs and baseline patient demographics were collected. A detailed physical examination and history was performed by a fellowship-trained provider, and a preliminary diagnosis and tentative treatment plan was formulated. The radiographs were then reviewed to determine whether the diagnosis and treatment plan was altered by addition of the radiographs. Patients who opted for radiographs then reported whether they felt the radiographs aided in diagnosis and treatment and whether the addition of the radiograph influenced their visit satisfaction. RESULTS A total of 220 patients met the inclusion criteria. Overall, 121 patients (55%) requested a radiograph. The mean age was 57.1 ± 16.1 years (range, 18 to 91 years). Lack of bachelor's degree (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2 to 6.2; P = 0.01), lack of previous contralateral shoulder pain (OR, 4.0; 95% CI, 2.0 to 8.2; P = 0.0001), and lack of a previous shoulder radiograph (OR, 8.4; 95% CI, 4.1 to 16.9; P < 0.0001) or MRI within the last 6 months (OR, 6.2; 95% CI, 1.4 to 26.8; P = 0.01) were independently associated with patient preference to obtain radiographs for atraumatic shoulder pain. Of the 121 patients who requested radiographs, 117 (96.7%) felt that radiographs improved their satisfaction. DISCUSSION Patients who obtained radiographs overwhelmingly reported its importance in improving visit satisfaction and diagnostic accuracy. Given the increasing emphasis on shared decision making, further study of patient factors influencing the decision to obtain routine radiographs will lead to more efficient practice management and potentially improved patient satisfaction. LEVEL OF EVIDENCE Level II (Diagnostic).

To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position.We retrospectively reviewed the medical records of 400 consecutive patients with a body mass index (BMI) of ≥30 kg/m who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Before June 2013, all patients were placed in standard beach chair positioning with no extra padding. After June 2013, patients had foam padding placed over their thighs underneath a wide safety strap and underneath the abdominal pannus. Flexion at the waist was minimized, and reverse Trendelenburg was used to position the shoulder appropriately. Patient demographic and surgical data, including age, sex, weight, BMI, presence of diabetes, procedure duration, American Society of Anesthesiologists (ASA) grade, and anesthesia type (general, regional, regional/general) were recorded. Symptoms of LFCN palsy were specifically elicited postoperatively in a prospective fashion and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh.The median age was 58.0 years, and the study consisted of 142 male (36%) and 258 female (64%) subjects. Five cases (3.6%) of LFCN palsy occurred with conventional beach chair positioning, and a single case (0.4%) occurred with the standardized positioning and padding technique (P = 0.02). Median age, sex, presence of diabetes, median BMI, surgery type, and surgical time were not significantly different between the patients who did and did not develop LFCN palsy. All cases resolved completely within 6 months.The occurrence of LFCN palsy following shoulder surgery in the beach chair position remains uncommon, even among obese patients. Use of a standardized positioning and padding protocol for obese patients in the beach chair position reduced the prevalence of LFCN palsy.Level III (prognostic).

Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.Level III, therapeutic study.

Highlights • Good perioperative outcomes seen in patients with COVID-19 that underwent hip fracture repair after 48 hours of admission • Short cephalomedullary nailing should be strongly considered over long nail for symptomatic COVID-19 patients with intertrochanteric hip fracture. • Regional anesthesia is preferred over general anesthesia in COVID-19 patients with hip fracture. • COVID-19 affects the immune system by releasing inflammatory proteins that can cause multiorgan failure. • Surgical repair should be reserved for patients with either mild or moderate COVID-19 infection.

Tendinopathy is a common musculoskeletal disorder characterized by chronic low-grade inflammation and tissue degeneration. Tendons have poor innate healing ability and there is currently no cure for tendinopathy. Studies elucidating mechanisms underlying the pathogenesis of tendinopathy and mechanisms mediating the genesis of tendons during development have provided novel targets and strategies to enhance tendon healing and repair. This review summarizes the current understanding and treatments for tendinopathy. The review also highlights recent advances in gene therapy, the potential of noncoding RNAs, such as microRNAs, and exosomes, which are nanometer-sized extracellular vesicles secreted from cells, for the treatment of tendinopathy.

Background Interscalene brachial plexus block (IBPB) has become a standard practice for perioperative analgesia for shoulder procedures. However, several side effects may occur owing to its anatomic location. We have chosen to evaluate vocal cord paresis and dysphonia following interscalene blocks. Methods After IRB approval, eight patients undergoing arthroscopic shoulder procedures were recruited into this prospective cohort study. Following informed consent, vocal cords were assessed by standardized fiberoptic evaluation. Subsequently, IBPB was performed under ultrasound (US) guidance. Patients were re-evaluated for vocal cord changes by a repeat fiberoptic assessment one hour following IBPB. Our primary outcome measure was incidence of vocal cord immobility. Results No patients had diminished vocal cord motion, dysphonia, or dysphagia. Conclusions Although larger studies are required to determine the true incidence of vocal cord paresis following US-guided IBPB, our results suggest that incidence of unwanted nerve blockade other than brachial plexus is much lower than that previously described.

INTRODUCTION Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain. The diagnostic utility of these radiographs is debatable. METHODS Patients presenting for the first time to a shoulder clinic with atraumatic shoulder pain received a plain radiographic series. After considering their medical history and physical examination, we made a preliminary diagnosis and formulated a tentative treatment plan. We then reviewed the radiographs and determined whether the addition of these radiographs altered the diagnosis and/or treatment. RESULTS A total of 343 patients met the inclusion criteria. Age >50 years (odds ratio, 3.3; 95% confidence interval, 1.9 to 5.8; P < 0.00001) and weakness in forward elevation (odds ratio, 2.9; 95% confidence interval, 1.6 to 5.4; P = 0.0003) were associated with the presence of radiographic findings. Plain radiographs altered the proposed diagnosis in only 14.9% (51/343) of cases. However, clinical management was changed in only 1.7% of cases. Plain radiographs had no effect on clinical management in 97.4% of patients younger than 50 years. DISCUSSION Plain radiographs rarely alter the diagnosis or affect management in the setting of atraumatic shoulder pain, particularly in patients younger than 50 years. Patients may be exposed to unnecessary radiation, and the healthcare system as a whole may be burdened with the increased cost of this imaging modality. LEVEL OF EVIDENCE Level II (diagnostic).

Background While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures. Materials and methods Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means. Results Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively. Conclusions Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available. Level of evidence Level IV, Systematic review.

Purpose To report on the prevalence of lateral femoral cutaneous nerve (LFCN) palsy in patients who had undergone shoulder surgery in the beach chair position and to identify patient and surgical risk factors for its development. Methods We retrospectively reviewed the medical records of 397 consecutive patients who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Patient demographic and surgical data including age, gender, weight, body mass index (BMI), diabetes, procedure duration, and anesthesia type (general, regional, regional/general) were recorded. LFCN palsy symptoms were recorded prospectively at the initial postoperative visit and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh. Results The median patient age was 59.0 years and consisted of 158 males (40%) and 239 (60%) females. Five cases of LFCN palsy were identified for a prevalence of 1.3%. These patients had a higher median weight (108.9 kg vs 80.7 kg, P = .005) and BMI (39.6 vs 29.4, P = .005) than the patients who did not develop LFCN palsy. Median age, gender, diabetes, and surgical time were not significantly different between the groups. All cases resolved completely within 6 months. Conclusions LFCN palsy after shoulder surgery in the beach chair position in our study has a prevalence of 1.3%, making it an uncommon complication. Patients with elevated BMI should be counseled about its possible occurrence after shoulder surgery in the beach chair position. Level of Evidence Level IV, prognostic.

Proximal humerus fractures remain one of the most common orthopaedic injuries, particularly in the elderly. Displaced fractures often require surgery, and management can be challenging because of comminution and poor bone quality. Despite advances in surgical technique and implant design, reoperation for malunion or nonunion of the tuberosity (arthroplasty) or screw penetration (open reduction and internal fixation) remains problematic. Recent studies have demonstrated acceptable results following nonsurgical management of displaced proximal humerus fractures in elderly, low-demand patients. In younger, more active patients, reduced function and pain that accompany select proximal humeral malunions are generally poorly tolerated. Surgical options for symptomatic, malunited tuberosities include osteotomy, tuberoplasty with rotator cuff repair and subacromial decompression, or decompression alone. Surgical neck malunion can be managed with corrective osteotomy and preservation of the native joint. Arthroplasty is reserved for complex malunions with joint incongruity. Surgical management of symptomatic proximal humeral malunion remains challenging, but good outcomes can be achieved with proper patient selection.

Clinical outcomes following upper extremity surgery among workers' compensation patients have traditionally been found to be worse than those of non-workers' compensation patients. In addition, workers' compensation patients take significantly longer to return to their jobs, and they return to their preinjury levels of employment at a lower overall rate. These unfavorable prognoses may stem from the strenuous physical demands placed on the upper extremity in this group of patients. Further, there is a potential financial benefit within this patient population to report severe functional disability following surgery. Orthopaedic upper extremity surgeons who treat workers' compensation patients should be aware of the potentially prolonged period before return to work after surgical intervention and should counsel this group of patients accordingly. Vocational training should be considered if a patient's clinical progress begins to plateau.

Septic arthritis of the shoulder girdle remains relatively uncommon, with Staphylococcus aureus and β-hemolytic streptococci the typical offending organisms in adult patients. Rare cases of Streptococcus viridans, an oral bacterium with low virulence, have been reported in the setting of septic arthritis, mostly involving the knee joint or the sternoclavicular joint. In this article, we report a case of Streptococcus mitis infection of the glenohumeral joint that likely resulted from hematogenous spread after oral trauma in a patient with poor underlying dentition. Prompt diagnosis followed by arthroscopic irrigation and débridement of the glenohumeral joint resulted in a satisfactory clinical outcome.

The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove. We asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally (“suprapectoral tenodesis”) by an arthroscopic technique? We retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12 months (mean, 28 months; range, 12–69 months). Two patients had persistent pain at 12 months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup. Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hypothesis Conservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing. Materials and methods We retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as "stiff" if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated "nonstiff." Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing. Results Ten patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort. Discussion Concerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period. Conclusions Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

Background The advantages of performing either a single- or 2-staged joint replacement has been reviewed extensively in the hip and knee arthroplasty literature, but far less data exist regarding total shoulder replacements. In the appropriate clinical setting, bilateral total shoulder arthroplasty yields excellent functional results with a low complication profile. Materials and methods We evaluated retrospectively the records of 13 consecutive patients (26 shoulders) who underwent staged bilateral primary total shoulder replacements by a single surgeon, with a minimum follow-up of 12 months for each side (range, 12.0-61.5). The interval between replacements averaged 7.4 months (range, 0.5-26.0). Results The mean unadjusted baseline Constant score for the first versus the second side was not significant (35 vs 41, P = .3). These scores improved to 73 and 72 by final follow-up (both P < .0001). Mean pain scores on the visual analog scale (VAS) improved from 6.9 to 0.9 (P < .0001). We found no difference in the estimated blood loss (EBL), operative time, or hospital length of stay (LOS) between the sides. Significantly higher mean scores were demonstrated in all components of the SF-36 questionnaire over a normalized cohort of U.S. age-matched males and females by final follow-up. All patients were satisfied with both procedures. Conclusion Staged, bilateral total shoulder arthroplasty results in excellent functional outcomes and high satisfaction in subjective patient assessment. We currently recommend a minimum of 6 weeks between replacements to allow for appropriate tissue healing and rehabilitation. Level of Evidence 4.

The use of subacromial injections to treat shoulder pain has remained one of the most common procedures for the practicing orthopedist, rheumatologist, and general practitioner. Despite this, many prospective studies have questioned the efficacy of corticosteroid injections compared with nonsteroidal anti-inflammatory drugs or injections of local anesthetics alone, or both, when used for the treatment of symptomatic rotator cuff disease. Accurate diagnosis of the etiology of a patient's shoulder pain and proper injection technique are important in achieving satisfactory clinical outcomes. Both extrinsic as well as intrinsic etiologies for rotator cuff disease should be considered and must be elucidated with appropriate physical examination techniques. Although subacromial injections appear straightforward, more recent cadaveric, radiographic, and clinical studies have demonstrated variable accuracy rates using the two common techniques. In addition, absolute sterile technique must be used because infections of the subacromial space after injections, although uncommon, have generally led to debilitating conditions. This article reviews the etiology and pathophysiology of rotator cuff disease and the indications and techniques for subacromial corticosteroid injections.

Purpose: Surgeons have noticed an increased incidence of finger lacerations associated with arthroscopic knot tying with solid-core suture material. This study examines glove perforations and finger lacerations during arthroscopic shoulder surgery. Methods: We collected 400 surgical gloves from 50 consecutive arthroscopic shoulder repair procedures using No. 2 solid-core sutures. Two surgeons using double gloves were involved in every case, with one being responsible for tying all knots. Powder-free latex gloves were worn in all cases. Knots consisted of a sliding stitch of the surgeon’s preference followed by 3 half-hitches via a knot-pusher instrument. All gloves were inspected grossly and then tested for tears with an electroconductivity meter. Results: The knot-tying surgeon had significantly more glove tears than the control (P .01). Tears were localized to the radial side of the index finger of the glove at the distal interphalangeal joint in all cases. Of the tying surgeon’s gloves, 68 (34%) were found to have tears. These included 17 inner gloves (17%) and 51 outer gloves (51%). If an inner glove was torn, the corresponding outer glove was torn in all cases. A mean of 3.96 knots were tied in each case. There was a significantly higher incidence of inner glove tears when more than 3 knots were tied (P .03). There was no significant difference in glove tears between suture types. Finger lacerations did occur in the absence of glove tears. However, in the presence of an inner glove tear, there was a statistically significant association with a finger laceration at the corresponding level (P .03). Conclusions: Intraoperative glove tears and subsequent finger lacerations occur with a high frequency when arthroscopic knots are tied with solid-core suture material. Risk can potentially be minimized by frequent glove changes or use of more durable, less penetrable gloves. Clinical Relevance: This study addresses surgeon and patient safety during arthroscopic shoulder surgery. Key Words: Glove perforation—Finger laceration—Shoulder arthroscopy—Arthroscopic knot tying.

Interscalene brachial plexus anesthesia is commonly used for outpatient arthroscopic shoulder procedures. Ultrasound guidance has helped to minimize the cardiac, neurologic, and pulmonary complications associated with this block. Although rarely reported, pneumothorax may occur as a result of direct lung injury and even in a delayed fashion. We present a case of tension pneumothorax in a patient undergoing arthroscopic rotator cuff repair under both interscalene regional and general anesthesia. Surgeons and anesthesiologists must remain aware that ultrasound-guided interscalene blocks may be associated with pneumothorax and must initiate treatment expeditiously.

The incidence of proximal humerus fractures in the elderly has been rising. Concomitantly, operative fixation with use of locking plates has been increasing. Postoperative complications of locking plate fixation, particularly in the setting of osteoporotic bone, include screw penetration of the articular surface, progressive fracture displacement, and avascular necrosis. Intraoperative techniques to enhance the fixation construct and reduce complications include use of rotator cuff sutures, bone void fillers (fibular strut allograft, cancellous allograft, autograft, bone cement), appropriate placement of divergent and shorter locking screws, and medial calcar reduction and support. More recent clinical and biomechanical studies suggest that use of these strategies may reduce complications after locked plating of osteoporotic proximal humerus fractures. Furthermore, a multidisciplinary approach to the evaluation and treatment of osteoporosis may be beneficial in these patients.

Background context The currently accepted surgical treatments for compressive cervical myelopathy include both anterior and posterior decompression. Anterior approaches including multilevel discectomy with fusion or vertebral corpectomy with strut grafting, both with and without instrumentation, have enjoyed successful outcomes, but have been associated with select postoperative complications. Laminoplasty has been developed to decompress the spine posteriorly while avoiding the spinal destabilization seen after laminectomy. Purpose The purpose of this article is to provide a review of the various techniques, biomechanical basis, predictive value of imaging modalities, clinical outcomes, and postoperative complications associated with cervical laminoplasty. Study design A review of the literature. Methods A comprehensive literature review using Medline was performed identifying relevant articles that addressed the techniques, clinical outcomes, and complications after cervical laminoplasty, as well as preoperative radiographic predictors of outcome. Results The various modifications of cervical laminoplasty have generally been associated with excellent clinical outcomes when used for myelopathy secondary to cervical spondylosis or ossification of the posterior longitudinal ligament (OPLL). Recent long-term studies have identified issues with this technique including axial neck pain, canal restenosis, nerve root palsy, diminished cervical motion, and loss of cervical lordotic alignment. Conclusions Cervical laminoplasty remains a reliable procedure for posterior decompression of the spine, but the optimal approach to cervical myelopathy must take into account both patient and disease characteristics, as well as the capabilities and experience of the surgeon.

Background: The Musculoskeletal Function Assessment is a validated, well-designed, self-administered questionnaire that is useful for determining health status. The modified Merle d'Aubigne clinical hip score is the most generally accepted clinical grading system for evaluating the results of acetabular fracture treatment. The purpose of the present study was to evaluate the relationship between the Musculoskeletal Function Assessment and modified Merle d'Aubigne scores in evaluating the results of acetabular fracture treatment. Methods: One hundred and fifty patients with an acetabular fracture met the criteria for inclusion in the present study, which included a minimum of two years of postoperative follow-up, a complete physical examination with use of the Merle d'Aubigne score, and successful completion of the Musculoskeletal Function Assessment questionnaire. Patients were stratified according to a number of factors, including the type of fracture and whether the fracture was an isolated injury or was part of a multiple-injury complex. The mean duration of follow-up was five years (range, two to seventeen years). Results: The mean modified Merle d'Aubigne score was 16.8 (range, 9 to 18), and the mean Musculoskeletal Function Assessment score was 24.9 (range, 0 to 79). The Spearman correlation coefficient between the Merle d'Aubigne score and the Musculoskeletal Function Assessment score was −0.61 (p < 0.0001). Stratification of the patients did not alter these overall results. However, the presence or absence of associated injuries was a significant factor for the Merle d'Aubigne score (p = 0.03). In addition, the Merle d'Aubigne score data were asymmetric, demonstrating a ceiling effect. Conclusions: The Musculoskeletal Function Assessment scores for these patients were relatively high compared with those for the normal population, indicating that complete return to a preinjury functional level is uncommon despite a good-to-excellent Merle d'Aubigne clinical score. Furthermore, the ceiling effect demonstrated by the Merle d'Aubigne score (despite its high correlation with the Musculoskeletal Function Assessment score) limits its usefulness as a method for evaluating the outcome of treatment of acetabular fractures. There have been few published clinical studies in which the Musculoskeletal Function Assessment score has been used as an outcome measure, and reference values are lacking. The present study provides initial guideline reference values for use in the evaluation of patients following an acetabular fracture.

Neuropathy of the lateral femoral cutaneous nerve can present as pain, decreased sensation, and/or burning or tingling on the anterolateral thigh. We present 4 cases of lateral femoral cutaneous nerve palsy following shoulder surgery in the beach chair position, all of which occurred in obese patients. This complication, to our knowledge, has never been reported in conjunction with the beach chair position. We believe that the neurapraxia was due to external compression by the patients' abdominal pannus. Full resolution of symptoms can be expected within 6 months following conservative management. A preoperative discussion regarding this complication should occur with obese patients undergoing shoulder surgery in the beach chair position.

Intertrochanteric hip fractures typically become deformed by the muscular and gravitational forces acting on the 2 main bony fragments. Traditional use of a fracture table for anatomical reduction normally corrects for the varus angulation, external rotation, and posterior sag that can occur, but, in select unstable and comminuted fractures, reduction may not be possible because of posterior sag and external rotation of the proximal fragment. These aspects of malreduction have been addressed in multiple ways, including use of unscrubbed assistants, crutches, internal rotation of the distal fragment by internal rotation of the foot, bumps and pads, and even intraoperative techniques. However, these techniques tend to adjust only 1 aspect of malreduction and may require intraoperative adjustment. In this article, we describe a novel surgical device, the pneumatic patient positioner, that can be used to address these deformities without the need for intraoperative adjustment.

Background: Mini-open reduction and percutaneous fixation of proximal humeral fractures historically results in good outcomes and a low prevalence of osteonecrosis reported with short-term follow-up. The purpose of this study was to determine the midterm results of our multicenter case series of proximal humeral fractures treated with percutaneous fixation. Methods: Between 1999 and 2006, thirty-nine patients were treated with percutaneous reduction and fixation for proximal humeral fractures at three tertiary shoulder referral centers. Twenty-seven of these patients were available for intermediate follow-up at a minimum of three years (mean, eighty-four months; range, thirty-seven to 128 months) after surgery; the follow-up examination included use of subjective outcome measures and radiographic analysis to identify osteonecrosis and posttraumatic osteoarthritis on radiographs. Results: Osteonecrosis was detected in seven (26%) of the total group of twenty-seven patients at a mean of fifty months (range, eleven to 101 months) after the date of percutaneous fixation. Osteonecrosis was observed in five (50%) of the ten patients who had four-part fractures, two (17%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Posttraumatic osteoarthritis, including osteonecrosis, was present on radiographs in ten (37%) of the total group of twenty-seven patients. Posttraumatic osteoarthritis was observed in six (60%) of the ten patients who had four-part fractures, four (33%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Conclusions: Intermediate follow-up of patients with percutaneously treated proximal humeral fractures demonstrates an increased prevalence of osteonecrosis and posttraumatic osteoarthritis over time, with some patients with these complications presenting as late as eight years postoperatively. Development of osteonecrosis did not have a universally negative impact on subjective outcome scores. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Aspergillus osteomyelitis is an extremely rare manifestation of invasive aspergillosis. Generally, patients in states of significant immune deficiency are very susceptible to invasive aspergillosis. We report a case of Aspergillus osteomyelitis of the proximal humerus in an immunocompetent patient that required aggressive oral antifungal therapy, surgical debridement, and placement of an antifungal-impregnated cement spacer. Subsequently, her shoulder was reconstructed using a reverse total shoulder prosthesis The clinical course, radiographic findings, histology, and management rationale are presented.

In 1961, DePalma [4] outlined the major surgical approaches to the shoulder girdle, describing in depth the local anatomy and providing a perioperative outline for surgeons operating in this region of the body. To date, the deltopectoral approach is the most commonly used in the treatment of the vast majority of fractures of the proximal humerus. The exposure allows application of plate and screw fixation for select fracture patterns, as well as for reconstruction of more complex fractures requiring arthroplasty. Surgeons can treat certain proximal humerus fractures requiring more posterior exposure with extension of the standard deltopectoral approach (Fig. 18). Fig. 18 Access to the anterior, superior, and posterior regions of the shoulder is by extension of the horizontal limb to the incision described previously. The horizontal limb is extended around the acromion process to the lateral half of the spine of the scapula; ... Levy and colleagues [11] described a more versatile approach that utilized a single anterior skin incision and a more posterior split in the deltoid combined with the traditional deltopectoral interval. This allows for preservation of the deltoid origin while concomitantly allowing for access to multiple regions of the shoulder. Furthermore, there were modifications to the original Judet approach [9] to the posterior scapula for scapular fractures [8, 12], allowing for less muscle stripping from the underlying scapula without compromising visualization of the major fracture lines. Clinical experience with these modifications demonstrated their utility for the majority of scapular body, neck, and intraarticular glenoid rim fractures [8]. Earlier anatomic dissection studies concerning the vascular supply to the humeral head suggested the predominance of the anterior circumflex humeral artery [6]; however, a more recent volumetric analysis using gadolinium uptake on MRI found the posterior circumflex artery is the dominant supply to the proximal humerus [7]. These authors therefore advocated the use of an extended anterolateral approach to the proximal humerus, exploiting the raphe between the anterior and middle heads of the deltoid [5]. Concern over further insult to the vascular supply of the proximal humerus following fracture spurred the use of minimally invasive techniques coupled with locked plating [13] and the reemergence of percutaneous pinning techniques with select fracture patterns [10]. As with all surgical approaches to the proximal humerus, surgeons must carefully identify and protect the axillary nerve as it courses anteriorly at a variable distance from the anterolateral acromion [2]. A recent cadaveric study [3] demonstrated that the position of the nerve changes with an abducted positioning of the shoulder. Advances in anesthetic options have also been presented in the orthopaedic literature, beyond the use of general anesthetics. Interscalene regional anesthesia are reportedly effective for both open and arthroscopic shoulder procedures, with a low complication rate [1]. The approaches to the shoulder DePalma outlined [4] have, in general, withstood the test of time. Subsequent modifications to these focused on minimizing soft tissue dissection and neurovascular injury, while maintaining the ability to adequately expose fractures and provide stable fixation.

While much literature has focused on the management of osteonecrosis of the femoral head, far less information is available regarding the treatment and outcomes of this disease in the proximal humerus. To a great extent, management of humeral head osteonecrosis has been inferred from studies involving the femoral head. The etiologies for this disease can be categorized most usefully as traumatic versus atraumatic. Regardless of the underlying etiology, the common pathway involves disruption of the arterial inflow or the venous outflow of the bone, with resultant osseous cell death. The general treatment strategies for humeral head osteonecrosis include nonoperative modalities for symptomatic early disease, with surgical intervention reserved for more advanced disease or those with recalcitrant pain.

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12–36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hypothesis Critical to the longevity of the reverse shoulder arthroplasty is initial rigid fixation of the glenosphere, determined in part by baseplate screw fixation. We studied screw fixation in baseplates placed in several different orientations. Methods Twelve, lightly-embalmed adult scapulae were implanted using a variable-angle and a fixed-angle baseplate. Baseplates were placed in three rotational positions: 1) 12/6 o'clock, 2) 20° rotation toward the coracoid, and 3) 20° rotation toward the scapular spine. Results Superiorly, perpendicular screws for the variable-angle baseplate in the 12 o'clock (39.7 mm) and coracoid (37.7 mm) position and angled screws in the coracoid position (37.5 mm) were found to be the longest. Inferiorly, screws holes made perpendicular to the baseplate yielded the longest screw lengths (37.4 mm), while inferiorly angled screws were shorter, especially in the anterior-inferior glenoid (16.8 mm). Conclusions Overall, baseplate rotation toward the spine yielded the lowest mean screw lengths. Proper initial rotation of the baseplate and screw orientation can optimize initial fixation of the glenosphere in reverse shoulder arthroplasty. Level of evidence Level IV, Case Series, Treatment Study.

Child abuse continues to be a serious problem that is likely to be encountered in all medical specialties, with orthopaedic surgeons commonly evaluating children having sustained musculoskeletal injuries. In busy emergency departments and clinics, junior residents shoulder much of the responsibility in identifying cases of abuse. We report the case of an otherwise healthy 18-month-old child, who presented to the emergency room with bilateral humeral shaft and corner fractures. These injuries were originally presented to the orthopaedic resident as having occurred from an accidental fall from a crib. The appropriate evaluation for a patient suspected of sustaining an injury from child abuse is reviewed.

Advancing age, lower preoperative hemoglobin levels, and more complex procedures are risk factors in transfusion requirements following shoulder arthroplasty.We retrospectively reviewed the records of 196 consecutive shoulder arthroplasties performed by a single surgeon (including 113 primary noncomplex total shoulder arthroplasties, 27 primary noncomplex hemiarthroplasties, 37 revision or complex arthroplasties, and 19 reverse shoulder arthroplasties). Logistic regression analysis was used to determine which clinical variables were associated with the need for postoperative transfusion.The overall transfusion rate was 43% (84/196). The presence of preoperative anemia (males13 g/dl, females12 g/dl), decreasing preoperative hemoglobin levels, female gender, increasing age, and implantation of a reverse shoulder arthroplasty were independent risk factors for postoperative transfusion. Operative time, estimated blood loss, anesthesia type, preoperative use of anticoagulants and body mass index (BMI) were not found to be predictive of transfusion.Our results corroborate the few existing studies regarding the effects of lower preoperative hemoglobin levels on transfusion risk following shoulder arthroplasty. In contrast to these studies, however, we found increasing age and the implantation of a reverse shoulder arthroplasty to be independent predictors for transfusion.The results of the present study support close postoperative monitoring of older, female patients (65 years), patients with preoperative anemia (males13 g/dl, females12 g/dl), and those undergoing reverse shoulder replacement. These patients should be educated before surgery of the potential need for postoperative blood transfusion.Level 4; Retrospective case series, no control group.

Isolated fractures of the trapezoid bone have been rarely reported in the literature, the mechanism of injury being an axial or bending load transmitted through the second metacarpal. We report a case of an isolated, nondisplaced trapezoid fracture that was sustained by direct trauma and subsequently treated successfully in a short-arm cast. Diagnostic and treatment strategies for isolated fractures of the trapezoid bone are reviewed as well as the results of operative and nonoperative treatment.

The case of a patient is presented in whom a No. 11 scalpel blade was inadvertently broken and embedded within the lateral femoral condyle during initial arthroscopic portal creation. After a thorough diagnostic arthroscopy and synovectomy to expose the distal femoral articular surface was unsuccessful, luoroscopy was performed to localize the blade fragment in orthogonal planes. The blade tip was eventually retrieved from its position below the surface of the cartilage. The details of the loss and recovery of the blade fragment reinforce that exceptional care must be taken and attention given during the creation of portals, particularly when resistance is encountered. Additionally, all instruments, especially scalpel blades, should be exam- ined carefully when removed from the knee joint.

We compared the clinical efficacy and side-effect profiles of aspirin, dextran 40, and low-molecular-weight heparin (enoxaparin) in preventing thromboembolic phenomena after hip fracture surgery. All patients admitted with a diagnosis of hip fracture to our institution between July 1, 1987, and December 31, 1999, were evaluated. Study inclusion criteria were age 65 years or older, previously ambulatory, cognitively intact, home-dwelling, and having a nonpathologic intertrochanteric or femoral neck fracture. Each patient received mechanical thromboprophylaxis (above-knee elastic stockings) and 1 pharmacologic agent (aspirin, dextran 40, or enoxaparin); patients who received aspirin were also given a calf sequential compression device. Meeting the selection criteria and included in the study were 917 patients. Findings included low incidence of thromboembolic phenomena (deep vein thrombosis, 0.5%-1.7%; pulmonary embolism, 0%-2.0%; fatal pulmonary embolism, 0%-0.5%) and no difference among the 3 pharmacologic agents in thromboembolic prophylaxis efficacy. Use of enoxaparin was associated with a significant increase (3.8%) in wound hematoma compared with dextran 40 (1.6%) and aspirin (2.4%) (P.01). The 3 agents were found not to differ with respect to mortality, thromboembolic phenomena, hemorrhagic complications, or wound complications.

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.

Background: The purpose of this study was to evaluate the results after operative treatment of fractures of the posterior wall of the acetabulum in relationship to the quality of the fracture reduction as assessed by postoperative two-dimensional computed tomography. Methods: The functional results for sixty-seven patients who had open reduction and internal fixation of an unstable fracture of the posterior wall of the acetabulum and the findings of two-dimensional computed tomography performed postoperatively were analyzed. Sixty-one patients were followed for a mean of four years after the injury, and the remaining six patients who had poor early results necessitating reconstructive surgery were followed for less than two years. All patients were evaluated preoperatively and postoperatively with use of three standard plain radiographs (one anteroposterior and two Judet 45° oblique pelvic radiographs) and a two-dimensional computed tomography scan. The functional outcome for the patients was evaluated with use of a modification of the clinical grading system described by Letournel and Judet. The radiographs were graded according to the criteria described by Matta. The two-dimensional computed tomography scans were used to determine fracture gap and offset measurements. Results: The clinical outcome was graded as excellent in thirty-one patients (46%), very good in twenty (30%), good in eight (12%), and poor in eight (12%). The final radiographic results were graded as excellent in fifty-three hips (79%), good in four (6%), fair in three (5%), and poor in seven (10%). There was a strong association between clinical outcome and final radiographic grade. Fracture reductions were graded as anatomic in sixty-five and imperfect in two, as determined with use of plain radiography. However, postoperative computed tomography revealed an incongruency (offset) of >2 mm in eleven hips and fracture gaps of ≥2 mm in fifty-two. Fracture gaps of ≥10 mm in any dimension or a total gap area of ≥35 mm 2 were associated with a poor result. The main risk factors for a poor result were a residual fracture gap width of ≥10 mm and osteonecrosis of the femoral head. Conclusions: The degree of residual fracture displacement is detected more accurately on postoperative computed tomography scans than on plain radiographs. The accuracy of surgical reduction as assessed on postoperative computed tomography is highly predictive of the clinical outcome. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Background: The purpose of the present study was to document the prevalence of, and recovery from, injuries of the femoral nerve associated with displaced acetabular fractures. Methods: From 1986 to 2001, 726 acetabular fractures were treated with open reduction and internal fixation. Four patients who had an injury of the femoral nerve associated with a displaced acetabular fracture were identified and were followed for a mean of 3.4 years. The nerve injury was iatrogenic in two patients and traumatic in two patients. Results: Clinically detectable quadriceps femoris motor function returned at an average of eighteen weeks (range, four to fifty-two weeks). All patients had satisfactory recovery of nerve function with a return of grade-4 or 5 motor power (the level of motor power needed to allow a normal gait) by an average of ten months (range, three to twenty-four months). Sensory recovery was incomplete but not debilitating. Conclusions: Preoperative examination of a patient who has an acetabular fracture should include an assessment of femoral nerve function. Regardless of whether the injury is traumatic or iatrogenic in origin, recovery of motor and sensory function without surgical exploration can be expected. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

This symposium is a collection of manuscripts dealing with current concepts in the evaluation and management of fractures of the shoulder girdle. Given the relatively high incidence of fractures about the shoulder, particularly those of the proximal humerus, operative techniques and implant technology continue to evolve. The use of locked plating has improved the treatment of proximal humerus fractures in elderly patients with osteoporosis. In patients with osteoporosis or comminuted fractures, however, fixation failure may still occur as the fracture settles during healing, potentially leading to screw penetration within the glenohumeral joint. Strategies to mitigate this complication may include the use of fibular strut allograft within the medullary canal and the use of suture augment within the rotator cuff combined with locked plating while avoiding long locked screws close to the subchondral surface. In general, nonoperative treatment for Neer one-part proximal humerus fractures restores function with minimal or no pain. The use of locked plating for more severe fracture patterns may be associated with worse function compared with its use in less displaced fractures. Further, age may predict function after treatment of displaced proximal humerus fractures less than the initial fracture pattern. Patients can more accurately be advised of their potential function after operative treatment. The incidence of deep venous thrombosis after shoulder surgery appears to be higher than previously thought. The use of aspirin and mechanoprophylaxis after surgery for proximal humerus fractures may provide sufficient treatment to reduce its incidence. Certain proximal humerus fractures are not amenable to plate and screw fixation and are more reliably treated with shoulder arthroplasty. The use of hemiarthroplasty for displaced proximal humerus fractures in the elderly has been associated with variable function but reliable pain relief. It has become clear the healing of the greater tuberosity to the humeral stem represents the most important factor in long-term function. Therefore, the use of a fracture-specific stem over a conventional humeral implant may improve tuberosity healing and, ultimately, patient function. The reverse shoulder prosthesis has been used successfully in the setting of rotator cuff-deficient arthritis. While requiring confirmation, its use for treating fractures appears to be less reliant on greater tuberosity healing for achieving pain relief and overhead elevation. Surgery for select displaced midshaft clavicle fractures has increased given the higher reported incidence of nonunion and symptomatic malunion. As such, implants for clavicle fracture fixation have evolved to lower-profile, precontoured locked plates. The use of precontoured plates may reduce the need for hardware removal, resulting in higher patient satisfaction and clinical results comparable to those of noncontoured conventional plates. Distal clavicle fractures represent a difficult subset of clavicle fractures. The use of precontoured distal clavicle plates with supplemental use of sutures around the coracoid or coracoclavicular screw fixation may more reliably restore function with minimal pain. In the case of operatively treated midshaft clavicle fractures, a plateau in clinical improvement appears to be reached at 1 year after surgery. This may provide a prognostic timeline of recovery for patients who undergo this surgery. Concern over prominent hardware used to treat clavicle fractures has led to further interest in the use of intramedullary devices. The use of the Rockwood pin for displaced midshaft clavicle fractures has been associated with a substantial complication profile, especially wound breakdown, pin prominence, and fracture nonunion. Cautious use of this implant should perhaps be advised. Titanium elastic intramedullary nailing, combined with careful intraoperative fluoroscopy to assess lateral penetration and a more conservative postoperative rehabilitation protocol, may represent an alternative to conventional plate and screw fixation. In general, strict indications for surgery of scapula fractures have remained elusive. The majority of the extraarticular fractures can be treated without surgery without complications while restoring function. The appropriate radiographic evaluation has traditionally included trauma views, which are variable in quality and positioning. The use of CT imaging with three-dimensional reconstruction may allow for more accurate and reproducible measurements of fracture angulation and displacement. Furthermore, surgery for substantially displaced or angulated scapular fractures appears to yield comparable rates of healing and restoration of function to patients managed nonoperatively for less displaced fractures. If surgery is indicated, selective incisions may provide sufficient access to the major fracture lines while minimizing soft tissue dissection. The authors of these articles are to be congratulated for their contributions to our understanding of the diagnosis, operative management, and potential complications of fractures of the shoulder girdle. It is my sincere hope that this symposium will stimulate discussion and raise further questions so as to continue to advance the treatment of shoulder fractures. I hope you enjoy this symposium. Fig. 1 Dr. Konrad I. Gruson is shown.