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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Background: The safety of controlled hypotension during arthroscopic shoulder procedures with the patient in the beach-chair position is controversial. Current practice for the management of intraoperative blood pressure is derived from expert opinion among anesthesiologists, but there is a paucity of clinical data validating their practice. The purpose of this study was to evaluate the effect of controlled hypotension on cerebral perfusion with use of continuous electroencephalographic monitoring in patients undergoing shoulder arthroscopy in the beach-chair position. Methods: Fifty-two consecutive patients who had undergone shoulder arthroscopy in the beach-chair position were enrolled prospectively in this study. All patients underwent preoperative blood pressure measurements, assignment of an American Society of Anesthesiologists (ASA) grade, and a preoperative and postoperative neurological and Mini-Mental State Examination (MMSE). The target systolic blood pressure for all patients was 90 to 100 mm Hg during surgery. Continuous intraoperative monitoring was performed with standard ASA monitors and a ten-lead portable electroencephalography monitor. Real-time electroencephalographic monitoring was performed by an attending-level neurophysiologist. Results: All patients violated at least one recommended limit for blood pressure reduction. The average decrease in systolic blood pressure and mean arterial pressure from baseline was 36% and 42%, respectively. Three patients demonstrated ischemic changes on electroencephalography that resolved with an increase in blood pressure. No adverse neurological sequelae were observed in any patient on the basis of the MMSE. Conclusions: This study provides the first prospective data on global cerebral perfusion during shoulder arthroscopy in the beach-chair position with use of controlled hypotension. Our study suggests that patients may be able to safely tolerate a reduction in blood pressure greater than current recommendations. In the future, intraoperative cerebral monitoring may play a role in preventing neurological injury in patients undergoing shoulder arthroscopy in the beach-chair position.

Background: Deep infection after primary reverse total shoulder arthroplasty is a devastating event and has an increased incidence compared with anatomic total shoulder arthroplasty. Recent reports in the hip and knee arthroplasty literature suggest that antibiotic-loaded bone cement may lower infection rates for primary arthroplasties. We conducted a retrospective cohort study to evaluate the effect of antibiotic-loaded bone cement vs plain bone cement on the prevention of deep infection after primary reverse total shoulder arthroplasty. Materials and methods: Four surgeons from their respective facilities participated in the retrospective cohort data collection. From 1999 to 2008, 501 consecutive primary reverse total shoulder arthroplasties were performed. Patients with revision of failed previous arthroplasties were excluded, and patients with any other previous shoulder procedure were included. Two groups were examined in this retrospective cohort: In group 1 (265 shoulders), the cement used for humeral fixation did not have antibiotics; in group 2 (236 shoulders), antibiotic-impregnated bone cement containing tobramycin, gentamycin, or vancomycin/tobramycin was used for fixation. Results: At an average postoperative follow-up of 37 months, no deep infection had developed in the 236 shoulders in group 2, whereas a deep infection had developed in 8 of the 265 shoulders (3.0%) in group 1. This difference between the groups was significant (P < .001). Conclusions: Antibiotic-impregnated bone cement was effective in the prevention of postoperative deep infection after primary reverse total shoulder arthroplasty during short-term follow-up. Level of evidence: Level III, Retrospective Case Control Design, Treatment Study. 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Recently, gender-specific designs of total knee replacement have been developed to accommodate anatomical differences between males and females. We examined a group of male and female distal femora matched for age and height, to determine if there was a difference in the aspect ratio (mediolateral distance versus anteroposterior distance) and the height of the anterior flange between the genders. The Hamann-Todd Collection provided 1207 skeletally mature cadaver femora. The femoral length, the anteroposterior height, height of the lateral and medial flanges and the mediolateral width were measured in all the specimens. The mechanical axis of the femur, the cut articular width and the aspect ratio were assessed. Statistical analysis of the effect of gender upon the aspect ratio and the lateral and medial flanges was undertaken, controlling for age, height and race. The mean aspect ratio of male femora was 1.21 (sd 0.07) and of female femora it was 1.16 (sd 0.06) (p < 0.001). There was no significant difference between male and female specimens in the mean size of the lateral flange (6.57 mm (sd 2.57) and 7.02 mm (sd 2.36), respectively; p = 0.099) or of the medial flange (3.03 mm (sd 2.47) and 3.56 mm (sd 2.32), respectively; p = 0.67). Future work in the design of knee prostheses should take into account the overall variability of the anatomy of the distal femur.

Background The lateral intercondylar ridge (resident's ridge) is considered to be an important landmark during anterior cruciate ligament reconstruction. Presently, no study exists describing the location of this vital landmark on plain radiographic images. Hypothesis Lateral intercondylar ridge location can be estimated on lateral plain film images. Study Design Descriptive laboratory study. Methods Lateral radiographic images were taken of 20 distal femora with metallic markers overlying the lateral intercondylar ridge. The length of Blumensaat's line and the distance from the anterior extent of Blumensaat's line to the point where the lateral intercondylar ridge intersects Blumensaat's line were measured. The ratio of these measurements was then determined (Blumensaat's-ridge ratio). The angle of the lateral intercondylar ridge with respect to Blumensaat's line (Blumensaat's-ridge angle) was also determined. Results The mean length of Blumensaat's line was 32.1 mm (95% confidence interval, 31.0–33.2 mm). The mean distance from the anterior extent of Blumensaat's line to the point where the lateral intercondylar ridge intersects Blumensaat's line was 25.3 mm (95% confidence interval, 24.3–26.3 mm). The mean Blumensaat's-ridge ratio was 0.79 (95% confidence interval, 0.77–0.81). The mean Blumensaat's-ridge angle was 75.5° (95% confidence interval, 72.0°–79.1°). Conclusion The lateral intercondylar ridge intersects Blumensaat's line at a point defined by multiplying the Blumensaat's line length by 0.79. From this point, the ridge runs at a 75.5° angle with respect to Blumensaat's line. Clinical Relevance Awareness of the radiographic location of the lateral intercondylar ridge may help confirm accurate tunnel placement when arthroscopic positioning is in doubt. Furthermore, femoral tunnel position can be quickly and accurately assessed in the outpatient setting in patients with unsatisfactory outcomes after anterior cruciate ligament reconstruction.

Complex proximal humerus fractures in older patients can be treated with hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA), with both providing good pain relief and function. This study compared the costs, complications, and outcomes of HA vs RSA after proximal humerus fracture in older patients. Patients 65 years or older who were admitted between January 2007 and August 2011 with a 3- or 4-part proximal humerus fracture and treated with HA or RSA were identified. Surgeries were performed at the same institution by 1 of 3 surgeons trained in trauma or shoulder surgery. Operating room costs, implant costs, total costs to the patient and hospital, and range of motion were compared. In the study group, 8 patients (7 women and 1 man; mean age, 77 years) received HA and 16 patients (13 women and 3 men; mean age, 77 years) received RSA. Hemiarthroplasty implant cost and operating room cost were $9140 and $8900 less than those of RSA, respectively ( P P Orthopedics. 2016; 39(4):230–234.]

Isolated greater tuberosity fractures make up a small subset of proximal humerus fractures. We conducted a study to evaluate the radiologic and clinical outcomes of patients who underwent a novel use of plate osteosynthesis in the treatment of displaced greater tuberosity fractures. Eleven consecutive patients with a displaced greater tuberosity fracture were treated. Mean age at surgery was 60.3 years old (range, 37-71 years). Mean follow-up was 27 months (range, 16-44 months). All 11 patients experienced radiographic union. Three of the 11 had a loss of anatomical reduction. Mean Penn Shoulder Score was 79, and mean Single Assessment Numeric Evaluation score was 72. At most recent follow-up, mean forward elevation was 147°, and mean external rotation was 25°. Plate osteosynthesis is a novel technique for the treatment of displaced greater tuberosity fractures. This technique resulted in excellent fracture reduction, a 100% union rate, minimal fracture migration, and good return of range of motion.

This study evaluated pre- and postoperative clinical and structural outcome data on anterosuperior rotator cuff tears involving the supraspinatus and subscapularis treated by arthroscopic methods. Between June 2006 and October 2007, a total of 155 consecutive patients underwent an arthroscopic repair for a supraspinatus or supraspinatus and infraspinatus (superior) rotator cuff tear. Of these, 44 (28%) were identified on preoperative imaging to have involvement of the subscapularis. Confirmation of subscapularis tears occurred during arthroscopic repair of the superior rotator cuff. If the subscapularis was found to be torn, it was documented, and an arthroscopic repair was performed. Postoperative clinical and radiographic outcomes were assessed with the belly press and lift-off tests, range of motion, strength, pain score, Constant score, and either a magnetic resonance imaging arthrogram or a computed tomography arthrogram at an average of 15 months postoperatively. Failure was determined based on rotator cuff integrity on radiologic studies. Sixteen of the 44 anterosuperior rotator cuff tears identified on preoperative imaging were found to have a full-thickness subscapularis tear requiring repair on arthroscopic examination. On preoperative imaging, subscapularis tears were all either grade 1 or grade 2 (no complete grade 3 tears). Mean follow-up was 16.9 months (range, 13–24 months). Compared with preoperative values, significant postoperative improvements occurred in Constant scores, forward flexion, strength, and pain scores ( P P

Rupture of the pectoralis major is an uncommon injury that can lead to pain, loss of strength, and cosmetic deformity. The purpose of this study was to analyze the outcome of pectoralis major repairs by a single surgeon. Twenty-four patients who underwent pectoralis major repair by the senior author (M.D.L.) between May 2005 and March 2011 were retrospectively identified. Patients were assessed at least 6 months postoperatively with the use of various questionnaires, including the Penn Shoulder Score, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, and Single Assessment Numeric Evaluation (SANE). All patients were men with an injury to the sternal head of the pectoralis. Most (16/24; 67%) patients sustained the injury while bench or incline bench pressing. Nineteen (79%) patients were successfully contacted for follow-up. Of these, an average preinjury bench press of 318 lb (range, 145–525 lb) was restored to an average of 264 lb (range, 100–500 lb) at follow-up. Average preoperative Penn Shoulder Score was 60 points (range, 33–77 points), improving to 94 points (range, 64–100 points) at last follow-up ( P =.011). Average postoperative ASES and SANE scores were 96 points (range, 60–100 points) and 93 points (range, 50–100 points), respectively. All but 1 patient were rated excellent (14/19; 74%) or good (4/19; 21%) by the Bak criteria. Operative treatment of pectoralis major rupture yields high patient satisfaction and allows predictable return of comfort, range of motion, cosmesis, and overall limb strength, with a slightly less predictable return of maximum bench press strength.

Metal-on-metal (MOM) hip resurfacing has become an increasingly popular treatment for young, active patients with degenerative disease of the hip, as bearing surfaces with better wear properties are now available. One proposed advantage of resurfacing is its ability to be successfully revised to total hip arthroplasty (THA). In addition, radiographic parameters that may predict failure in hip resurfacing have yet to be clearly defined. Seven MOM resurfacing arthroplasties were converted to conventional THAs because of aseptic failure. Using Harris Hip Scores (HHS) and Short Form 12 (SF-12) questionnaire scores, we compared the clinical outcomes of these patients with those of patients who underwent uncomplicated MOM hip resurfacing. In addition, all revisions were radiographically evaluated. Mean follow-up periods were 51 months (revision group) and 43 months (control group). There was no significant difference between the 2 groups' HHS or SF-12 scores. There was no dislocation or aseptic loosening after conversion of any resurfacing arthroplasty. Valgus neck-shaft angle (P.03) was associated with aseptic failure of MOM hip resurfacing. Conversion of aseptic failure of hip resurfacing to conventional THA leads to clinical outcomes similar to those of patients who undergo uncomplicated hip resurfacing. The orientation of the femur and the components placed play a large role in implant survival in hip resurfacing. More work needs to be done to further elucidate these radiographic parameters.

Pediatric Chance fractures are uncommon injuries. They are the result of a flexion-distraction force applied to the spine, and most commonly occur from motor vehicle accidents in which passengers are wearing lap seat belts as opposed to 3-point restraints with a chest strap. Neurologic injuries are rarely associated with Chance fractures in children, but accompanying intraabdominal injuries are often found and carry a potential for significant morbidity. We present 3 siblings in a minivan who were involved in a high-speed motor vehicle accident and as a result of wearing their 3-point restraints improperly, suffered Chance fractures. None had neurologic dysfunction, but 2 had serious intra-abdominal injuries requiring surgical repair. All 3 Chance fractures were treated with cast immobilization. This case report shows the importance of wearing 3-point restraints properly while traveling in a motor vehicle.

Proximal humerus fractures occur frequently, and treatment remains controversial. This study compares stiffness in axial loading for 3 methods of fixation (locking compression plate, standard (nonlocking) proximal humerus plate, and blade plate) in a 3-part proximal humerus fracture model. Twelve paired proximal humeri were obtained from embalmed human cadavers and separated into 3 groups. Osteotomies of the surgical neck and greater tuberosity were created to simulate a 3-part proximal humerus fracture. After fixation, constructs were axially loaded in 20 degrees of abduction for 200 cycles in an Instron materials testing machine (Norwood, Massachusetts). The blade plate (mean, 146.87+/-28.9 N/mm) demonstrated 29% more mean stiffness than the standard plate (mean, 113.0+/-22.3 N/mm; P=.19). The locking compression plate (mean, 130.71+/-39.2 N/mm) exhibited 15% greater stiffness compared to the standard plate in our 3-part model (P=.58). The blade plate demonstrated 12% greater stiffness than the locking compression plate (P=.64). There was no significant difference in mean stiffness between the fixed-angle devices and the standard plate. Future in vitro and clinical studies of plate devices for proximal humerus fractures would be worthwhile to determine the benefits and limitations of various implants for specific types of fractures, including clinical performance and cost of care.

Posterior glenoid bone loss often is seen in association with glenohumeral osteoarthritis. Many different techniques have been proposed to account for this bone loss during total shoulder arthroplasty, the most popular being eccentric anterior reaming. However, the amount of correction that can be achieved has not been been well quantified. The purpose of this study was to define the amount of eccentric posterior glenoid wear that can be corrected by anterior glenoid reaming. Eight cadaveric scapulae were studied. Simulations of posterior glenoid wear in 5 degrees increments were performed on each scapula. The specimens were then eccentrically reamed to correct the deformity. Anteroposterior width, superior-inferior height, and the best-fit pegged glenoid prosthesis size were measured. Anterior reaming to correct a 10 degrees posterior defect resulted in a decrease in anteroposterior glenoid diameter from 26.7+/-2.5 mm to 23.8+/-3.1 mm (P=.006). In 4 of 8 specimens, placing a glenoid prosthesis was not possible after correcting a 15 degrees deformity because of inadequate bony support (N=2), peg penetration (N=1) or both (N=1). A 20 degrees deformity was correctable in 2 of 8 specimens and only after downsizing the glenoid component. Anterior glenoid reaming to correct eccentric posterior wear of >10 degrees results in significant narrowing of the anteroposterior glenoid width. A 15 degrees deformity has only a 50% chance of successful correction by anterior, eccentric reaming. Orthopedic surgeons need to be cognizant of this in their preoperative planning for total shoulder arthroplasty.

Introduction: The development of effective treatments for osteoarthritis (OA) has been hampered by a poor understanding of OA at the cellular and molecular levels. Emerging as a disease of the ‘whole joint’, the importance of the biochemical contribution of various tissues, including synovium, bone and articular cartilage, has become increasingly significant. Bathing the entire joint structure, the proteomic analysis of synovial fluid (SF) from osteoarthritic shoulders offers a valuable ‘snapshot’ of the biologic environment throughout disease progression. The purpose of this study was to identify differentially expressed proteins in early and late shoulder osteoarthritic SF in comparison to healthy SF. Methods: A quantitative 18 O labeling proteomic approach was employed to identify the dysregulated SF proteins in early (n = 5) and late (n = 4) OA patients compared to control individuals (n = 5). In addition, ELISA was used to quantify six pro-inflammatory and two anti-inflammatory cytokines. Results: Key results include a greater relative abundance of proteins related to the complement system and the extracellular matrix in SF from both early and late OA. Pathway analyses suggests dysregulation of the acute phase response, liver x receptor/retinoid x receptor (LXR/RXR), complement system and coagulation pathways in both early and late OA. The network related to lipid metabolism was down-regulated in both early and late OA. Inflammatory cytokines including interleukin (IL) 6, IL 8 and IL 18 were up-regulated in early and late OA. Conclusions: The results suggest a dysregulation of wound repair pathways in shoulder OA contributing to the presence of a ‘chronic wound’ that progresses irreversibly from early to later stages of OA. Protease inhibitors were downregulated in late OA suggesting uncontrolled proteolytic activity occurring in late OA. These results contribute to the theory that protease inhibitors represent promising therapeutic agents which could limit proteolytic activity that ultimately leads to cartilage destruction.

We report a multicenter long-term follow-up study of patients with septic arthritis of the hip during infancy or childhood. Group I ("infantile") consisted of patients with onset before age 3 months, and Group II ("childhood") consisted of patients in whom onset occurred after age 3 months. Patients were specifically examined for this review. Generally, patients at follow-up had poor anatomic appearance radiographically and scored poorly on the Harris rating system. However, pain and activity restriction were minimal. Patients who were not treated operatively tended to function better than patients who underwent operative reconstruction.

Summary Nine hips in eight patients were available at a mean follow-up of 31.5 years for participation in a retrospective functional and radiographic analysis for the purpose of examining the late effects of infantile septic hip arthritis in a group untouched by reconstructive hip surgery. Results suggest that reconstructive efforts following hip joint sepsis designed for relocation of an inadequate femoral head for persistent dislocation or for transference of the greater trochanteric epiphysis into the acetabulum may not yield results comparable to nonoperative treatment.