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In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Objective The objectives of this study were to: 1) identify predictors of subsequent surgery following initial treatment of proximal humerus fractures (PHF); and 2) generate valid risk prediction tools to predict subsequent surgery. Methods We identified PHF patients ≥ 50 years from 2004 to 2015 using health datasets in Ontario, Canada. We used procedural codes to classify patients into treatment groups of: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used procedural and diagnosis codes to capture subsequent surgery within two years post fracture. We developed regression models for two thirds of each group to identify predictors of subsequent surgery, and the regression equations to develop risk tools to predict subsequent surgery. We used the final third of each cohort to evaluate the discriminative ability of the risk tools using c-statistics. Results We identified 20,897 PHF patients, 2,414 treated with fixation, 1,065 with replacement, and 17,418 treated conservatively. Predictors of reoperation following fixation included bone grafting, and nail or wire fixation vs. plate fixation, while poor bone quality was associated with reoperation following initial replacement. In conservatively treated patients, more comorbidities were associated with subsequent surgery, while age 70+, and discharge home following presentation lowered the odds of subsequent surgery. The risk tools were able to discriminate with c-statistics of 0.75-0.88 (derivation) and 0.51-0.79 (validation). Conclusion Our risk tools showed good to strong discriminative ability for patients treated with fixation and conservatively. These data may be used as the foundation to develop a clinically informative tool. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment.The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χTwo hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P.001), Single Assessment Numeric Evaluation (P.001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P.001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P.001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P.001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes.YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.

BACKGROUND Irreparable rotator cuff tears (IRCTs) pose treatment challenges both clinically and financially. As cost-effectiveness initiatives are prioritized, value-based health care delivery models are becoming increasingly common. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 common surgical treatment options for IRCTs: superior capsular reconstruction (SCR), arthroscopically assisted lower trapezius tendon transfer (LTTT), and reverse shoulder arthroplasty (RSA). METHODS Between 2018 and 2020, 155 patients who underwent shoulder surgery at a single institution for IRCT with minimal to no arthritis were identified. Procedures performed included 20 SCRs, 47 LTTTs, and 88 RSAs. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. RESULTS Mean standardized costs were as follows: preoperative evaluation SCR $507, LTTT $507, and RSA $730; index surgical hospitalization SCR $19,675, LTTT $15,722, and RSA $16,077; and postoperative care SCR $655, LTTT $686, and RSA $404. Significant differences were observed in the index surgical costs (P < .001), with SCR incurring an additional average cost of $3953 and $3598 compared with LTTT and RSA, respectively. The 90-day complication, reoperation, and readmission rates were 0%, 0%, and 0% in the SCR group; 2.1%, 0%, and 0% in the LTTT group; and 3.4%, 0%, and 1.1% in the RSA group, respectively. With the numbers available, differences among the 3 surgical procedures with respect to complication (P = .223), reoperation (P = .999), and readmission rates (P = .568) did not reach statistical significance. CONCLUSIONS The mean standardized costs for the treatment of 3 common IRCT procedures inclusive of 60-day workup and 90-day postoperative recovery were $16,915, $17,210, and $20,837 for LTTT, RSA (average added cost $295), and SCR (average added cost $3922), respectively. This information may provide surgeons and institutions with cost-related information that will become increasingly relevant with the expansion of value-based surgical reimbursements.

There remains a paucity of information analyzing which factors most influence preoperative expectations for patients undergoing reverse total shoulder arthroplasty (RTSA). The purposes of our study were to characterize preoperative patient expectations for those scheduled to undergo RTSA and to determine the impact of demographic factors, shoulder function, and shoulder pain on these preoperative expectations.Patients were prospectively recruited into the study if they were scheduled to undergo an elective unilateral primary RTSA for a diagnosis of glenohumeral arthritis. Preoperative patient expectations were evaluated using the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Patients also completed the American Shoulder and Elbow Surgeons shoulder score, the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-Upper Extremity computer adaptive test (version 2.0), the PROMIS Pain Interference (PI) computer adaptive test (version 1.1), the PROMIS Depression computer adaptive test (version 1.0), visual analog scores, and an itemized satisfaction questionnaire, which paralleled the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Demographic data and preoperative shoulder range of motion (ROM) were also recorded.A total of 107 patients scheduled to undergo RTSA were included in the study. Relief of daytime pain (n = 91, 85%), improvement in self-care (n = 86, 80%), and improvement in shoulder ROM (n = 85, 79%) were most commonly cited as "very important" expectations. In the item-specific analysis, lower PROMIS Upper Extremity scores were correlated with greater expectations for the ability to reach sideways (P = .015) and the ability to perform daily activities (P = .018). Patients with lower shoulder ROM had greater expectations for improved shoulder ROM (internal rotation with arm at 90°, P = .004) and an improved ability to perform daily activities (forward elevation, P = .038; abduction, P = .009). In the cumulative analysis, a greater number of very important expectations was associated with African American race (P = .013), higher PROMIS PI score (r = 0.351, P = .004), and lower overall preoperative satisfaction (r = 0.334, P.001).Patients scheduled to undergo RTSA have the greatest expectations for relief of daytime pain, improvement in self-care, and improvement in shoulder ROM. Patients with limited preoperative ROM have greater expectations for improvement in self-care and the ability to perform daily activities in addition to expectations for improvement in shoulder ROM. Greater overall expectations for surgery were not associated with preoperative physical function but were instead associated with lower preoperative satisfaction and higher PROMIS PI scores.

To evaluate the diagnostic reliability of ultrasonography (US) and magnetic resonance imaging (MRI) for subscapularis (SSC) tears with shoulder arthroscopy as the gold standard and to investigate the diagnostic value of 2 MRI signs (lesser tuberosity cysts and subcoracoid cysts) for SSC tears.We consecutively enrolled 437 patients who were scheduled to undergo arthroscopic rotator cuff repair from January 2019 to December 2020. Patients with previous shoulder surgery or shoulder fracture, recurrent shoulder instability, and systemic inflammatory disease were excluded. Preoperative US and MRI of the shoulder were performed and interpreted with a standardized approach. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of US and MRI were calculated using arthroscopic findings as the gold standard.Of the 437 patients, 157 had SSC tears confirmed at the time of arthroscopy, 126 of whom had partial-thickness tears. US correctly diagnosed 122 of 157 patients with SSC tears, with an overall sensitivity of 77.7% (confidence interval [CI] 70.6%-83.5%), which was significantly greater than that of MRI (49.7%, CI 42.0%-57.4%, P.001). For partial-thickness SSC tears, US correctly diagnosed 93 of 126 positive patients and 276 of 311 negative patients. This resulted in a sensitivity of 73.8% (CI 65.5%-80.7%), specificity of 88.7% (CI 84.8%-91.8%), and accuracy of 84.4% (CI 80.7%-87.5%). As with MRI, the sensitivity, specificity, and accuracy were 38.1% (CI 29.7%-47.2%), 86.5% (CI 82.3%-89.9%), and 72.5% (CI 68.2%-76.5%), respectively. Lesser tuberosity cysts and subcoracoid cysts were 2 MRI signs with high specificity (98.2% and 94.6%); however, their sensitivities were relatively low (19.8% and 33.8%).US is a reliable and accurate diagnostic method for SSC tears, especially in easily missed partial-thickness tears. Lesser tuberosity cyst and subcoracoid cyst are highly specific but insensitive MRI signs for SSC tear.Level I, diagnostic, testing of previously developed diagnostic criteria.

Background Interscalene blocks are becoming increasingly common for shoulder surgeries. This study primarily aimed to demonstrate the efficacy and complications and the secondarily to investigate the anesthesia-related time and patient satisfaction of an ultrasound-guided interscalene block performed by an orthopedic surgeon. Methods We retrospectively reviewed the medical records of 1,322 consecutive patients (arthroscopic, 1225 cases; open, 97 cases) with a mean age of 64.2 years, who underwent shoulder surgery, (arthroscopic or opensurgery), under an ultrasound-guided interscalene block performed by an orthopedic surgeon at a single institution between December 2012 and December 2019. We investigated patient satisfaction, block success rates, and complications and also compared the anesthesia-related time of an interscalene block with that of general anesthesia (428 cases, arthroscopic, 257 cases; open, 171 cases) for shoulder surgery with patients in the beach chair position during the same period. Difference between total anesthesia time and surgical time was defined as anesthesia-related time. Results Approximately 98.3% of patients were satisfied with an interscalene block, and the block success rate on the first attempt was 99.9%. Total complication incidence was 2.3%, with no recorded life-threatening complications. Anesthesia-related times were significantly shorter in the interscalene block group than in the general anesthesia group (45 ± 14 min vs. 100 ± 26 min, P Conclusions An ultrasound-guided interscalene block performed by an orthopedic surgeon for shoulder surgery is effective and safe, requires less time, and has a high patient acceptance rate, making it a feasible and alternative to the block performed by anesthesiologists.

To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy.Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up.Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P.01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P.01); Single Assessment Numeric Evaluation (47.0 to 84.5, P.05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P.01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02).Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction.IV, retrospective case series.

The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA.Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function.A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up.The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

Background Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution. Methods From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection. Results Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection. Conclusion Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Background As reverse shoulder arthroplasty (RSA) cases increase, so too will the need to revise subsequent failures. Many of the complications associated with revising anatomic total shoulder and hemiarthroplasty have been adequately addressed by RSA including glenoid bone deficiency, instability, and functional outcomes. However, the risk for complication when revising a failed reverse prosthesis may be more pronounced with increased bone and soft tissue deficiency. The ability for the reversed prosthesis to accommodate these insufficiencies following a prior reversed prosthesis is unclear. Methods PubMed, Embase, and Google Scholar were queried for articles which fit the inclusion criteria of a reversed prosthesis used to revise a failed primary reverse prosthesis with a minimum follow-up of 12 months and clinical outcome reporting. Results After exclusions, 9 studies reporting on 242 reverse shoulders with a mean follow-up of 40.29 months were analyzed. The differences between preoperative and postoperative weighted means were not significant for Constant (P = .26), American Shoulder and Elbow Surgeons Shoulder score (P = .61), SSV (P = .57), and visual analog scale for pain (P = .48). Functional improvements in elevation (74°-102°) and external rotation (18°-21°) were consistent with those reported for primary reverse procedures, although differences in preoperative and postoperative measures were not statistically significant. Patient satisfaction was 89% with a major complication rate of 25%. Discussion The reverse shoulder prosthesis has proven satisfactory in revising hemiarthroplasty and anatomic total shoulder arthroplasty. The current results indicate RSA is also a satisfactory treatment option when revising a prior reverse prosthesis. Inherent to revision shoulder surgery is the obstacle of humeral and glenoid bone loss, an attenuated soft-tissue envelope, and instability. The reverse prosthesis may adequately address these commonly confronted difficulties with its inherent design characteristics. RSA provides a secure glenoid fixation for bone grafting, the ability to increase construct stability with component sizing, and a reliance on the deltoid for function. As our learning about revision of RSA improves, so will our ability to preemptively address potential issues which may lead to decreased complications in these cases. Despite the 25% rate of major complication, patients reported satisfaction of 89% which demonstrates the improvements in function and pain relief that are provided by the reverse prosthesis.

Background Recent literature supports that outpatient total shoulder arthroplasty (TSA) is a safe alternative to the traditional inpatient setting in appropriately selected patients; however, one concern with outpatient TSA is the inability to administer 24 hours of intravenous (IV) prophylactic antibiotics. The purpose of this study was to determine the infection and revision rates after outpatient TSA using single-dose preoperative IV antibiotics in an ambulatory setting and compare those to TSA performed inpatient with 24 hours of IV antibiotics. Methods An institutional database query was used to identify patients undergoing either primary anatomic TSA or reverse TSA. Patients were grouped into inpatient receiving 24 hours of IV antibiotics or outpatient receiving a single dose of IV antibiotics. Outcomes measured included overall infection (superficial and deep) and revision rates (infectious or noninfectious indications). Timing of infection was categorized as early (diagnosis 3 months postoperatively). Patient demographics and comorbidities were analyzed. Results Of the total 1022 patients identified, 896 were inpatient and received 24 hours of IV antibiotics, and 126 patients were outpatient and received a single dose of IV antibiotics prior to TSA at an ambulatory surgery center. Average follow-up was 23 ± 21 and 18 ± 16 months for the 24-hour antibiotic cohort and single-dose cohort, respectively. The 896 patients receiving 24-hour antibiotics were on average 10.3 years older than the 129 patients who received a single dose ( Conclusion Postoperative infection rates were low in both groups. There were no statistically significant differences in postoperative infection or revision rates. Patients in the single-dose cohort were significantly younger and had fewer comorbidities than patients in the 24-hour cohort; however, the single-dose cohort was more likely to have had previous nonarthroplasty shoulder surgery, which was most likely related to stricter patient selection criteria. The results of this study suggest that a single dose of IV antibiotic prophylaxis can be safely used in patients having outpatient TSA in an ambulatory center. Level of Evidence. Level III; Retrospective Cohort

Complications and revisions following anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty have deleterious effects on patient function and satisfaction. The purpose of this study is to evaluate patient-specific, implant-specific and technique-specific risk factors for intraoperative complications, postoperative complications, and the occurrence of revisions after aTSA and rTSA.A total of 2964 aTSA and 5616 rTSA patients were enrolled in an international database of primary shoulder arthroplasty. Intra- and postoperative complications, as well as revisions, were reported and evaluated. Multivariate analyses were performed to quantify the risk factors associated with complications and revisions.aTSA patients had a significantly higher complication rate (P = .0026) and a significantly higher revision rate (P.0001) than rTSA patients, but aTSA patients also had a significantly longer average follow-up (P.0001) than rTSA patients. No difference (P = .2712) in the intraoperative complication rate was observed between aTSA and rTSA patients. Regarding intraoperative complications, female sex (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.17-3.68) and previous shoulder surgery (OR 2.9, 95% CI 1.73-4.90) were identified as significant risk factors. In regard to postoperative complications, younger age (OR 0.987, 95% CI 0.977-0.996), diagnosis of rheumatoid arthritis (OR 1.76, 95% 1.12-2.65), and previous shoulder surgery (OR 1.42, 95% CI 1.16-1.72) were noted to be risks factors. Finally, in regard to revision surgery, younger age (OR 0.964, 95% CI 0.933-0.998), more glenoid retroversion (OR 1.03, 95% CI 1.001-1.058), larger humeral stem size (OR 1.09, 95% CI 1.01-1.19), larger humeral liner thickness or offset (OR 1.50, 95% CI 1.18-1.96), larger glenosphere diameter (OR 1.16, 95% CI 1.07-1.26), and more intraoperative blood loss (OR 1.002, 95% CI 1.001-1.004) were noted to be risk factors.Studying the impact of numerous patient- and implant-specific risk factors and determining their impact on complications and revision shoulder arthroplasty can assist surgeons in counseling patients and guide patient expectations following aTSA or rTSA. Care should be taken in patients with a history of previous shoulder surgery, who are at increased risk of both intra- and postoperative complications.

ResumoAs lesões do manguito rotador do ombro podem ter diversas configurações, e são divididas e/ou classificadas conforme o tamanho da lesão, o tendão envolvido, suas combinações, e se existe a possibilidade de reparo. As lesões irreparáveis do subescapular, assim como as lesões irreparáveis anterossuperiores, podem gerar disfunção do ombro devido à perda dos depressores da cabeça umeral, o que causa dor e limitação funcional. Entre as alternativas terapêuticas estão as transferências miotendíneas, sendo a técnica de transferência do peitoral maior para a tuberosidade menor a mais estudada e difundida nas últimas décadas. No entanto, alguns estudos anatômicos sugerem que o grande dorsal seja uma alternativa mais adequada para o tratamento dessas lesões por apresentar vetores de força mais parecidos com os do subescapular, além de apresentar resultados promissores nas avaliações clínicas de curto seguimento. Este trabalho tem o objetivo de descrever a técnica cirúrgica desenvolvida para transferência do grande dorsal nas lesões irreparáveis do subescapular e anterossuperiores do manguito rotador.

BACKGROUND Return to work (RTW) after surgery for a work-related rotator cuff disorder (WRRCD) is often difficult. The study's purpose was to identify preoperative factors predicting RTW. METHODS Ninety-two workers with a WRRCD were identified by four surgeons. Before surgery, the workers completed a series of standardized questionnaires related to working conditions, health, and health beliefs. They were followed up prospectively for 20 months. Statistical analysis was based on single and multiple-factor Cox models of the duration of absence from the time of surgery until RTW. RESULTS The median age at inclusion was 49 years (27-62), with 52 women included (57%). Sixty-one subjects (66%) were employed in highly physically demanding jobs. Forty-two (46%) stayed at work until their surgery, whereas preoperative sick leave exceeded 100 days in 20 subjects (21%). Twenty months after surgery, 14 were still not back at work. For the other participants, the mean duration until RTW was 225 days (SD 156). In the fully adjusted model, variables that were significantly predictive of the duration until RTW were: work physical demand levels, preoperative sick leave, the number of body parts causing pain or discomfort in the last 12 months, self-assessed 2-year workability, and the Readiness for RTW (RRTW) Scale. CONCLUSIONS Several physical, psychological, and work-related factors, easily recorded, can be identified preoperatively. They may be predictive of delayed return, loss of employment, or employability as a result of shoulder surgery.

Background Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR). Methods Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery. Results A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05). Conclusion Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.

Context: Arthroscopic surgical repair of the shoulder is recommended when conservative treatment for shoulder instability (SI) fails. However, many patients undergoing this procedure do not return to same level of activity. Psychological factors and muscle strength have been shown to be associated with postoperative outcomes in other musculoskeletal conditions. Objective: To investigate the association between fear avoidance, muscle strength, and short-term function in patients after surgical SI repair. Methods: Twenty-five male patients who underwent shoulder surgery following at least one event of SI were included in this study. Evaluations of fear avoidance related to physical activity and disability were performed at baseline (during the first encounter with the physical therapist) and 7 to 8 weeks postsurgery. Fear avoidance beliefs were assessed using the Fear Avoidance Beliefs Questionnaire. Disability was assessed using the Disabilities of Arm, Shoulder, and Hand questionnaire and the Western Ontario SI index. The follow-up evaluation (weeks 7–8) included measurement of maximal isometric strength of the internal and external rotators. Nonparametric Kendall tau was used to determine the correlations between baseline fear avoidance, muscle strength, and disability at follow-up. Results: Disabilities of Arm, Shoulder, and Hand questionnaire at follow-up was significantly correlated with baseline Disabilities of Arm, Shoulder, and Hand questionnaire (τ = .520, P τ = .399, P = .008), and both internal rotator (τ = −.400, P = .005) and external rotator strength (τ = −.353, P = .014). Western Ontario SI index at follow-up was moderately correlated with baseline Western Ontario SI index (τ = .387, P = .007), internal rotator (τ = −.427, P = .003), and external rotator (τ = −.307, P = .032), but not with baseline Fear Avoidance Beliefs Questionnaire (τ = .22, P = .145). Conclusions: The results indicate a possible association between fear avoidance beliefs and short-term disability. Further studies are warranted to better explore and understand these relationships.

Background Our purpose was to identify the 100 most cited articles in the shoulder surgery literature published in past decade and to compare them with the 100 most cited “classic” shoulder surgery articles to identify trends in the topics of shoulder research. Methods Using the term “shoulder,” we searched the Clarivate Analytics’ Web of Science Core Collection database for 2 periods: 2010 through 2019 (“contemporary group,” n = 12,394) and 1900 through 2009 (“classic group,” n = 8790). We used the database sort function to order articles by number of citations. Titles, abstracts, and, when necessary, full text were screened to determine relevance to orthopedic shoulder topics until the 100 most cited articles were determined for each group. We analyzed the following article characteristics: title, author(s), publication year, journal, geographic origin, article type (clinical vs basic research), study design, and level of evidence (for clinical articles). P Results The 3 journals with the most articles in the contemporary group were the American Journal of Sports Medicine (AJSM) (28%), the Journal of Shoulder and Elbow Surgery (JSES) (28%), and the Journal of Bone and Joint Surgery, American volume (JBJS Am) (23%). The top 3 journals in the classic group were JBJS Am (45%), AJSM (16%), and JSES (15%). The 3 most frequent topics in the contemporary group were rotator cuff tear (43%), instability (14%), and fractures (10%); those in the classic group were pathoanatomy (29%), rotator cuff (28%), and instability (17%). Compared with the classic group, the contemporary group had more articles on outcomes of common shoulder procedures, including rotator cuff repair (25% vs. 17%), arthroplasty (21% vs. 15%), arthroscopy (17% vs. 11%), reverse shoulder arthroplasty (13% vs. 7%), and the Latarjet procedure (7% vs. 2%). More articles reporting complications were found in the contemporary (9%) than in the classic (2%) group (P = .03). The contemporary group contained articles on topics not found in the classic group, such as platelet-rich plasma (8%), scaffolds (3%), infection (3%), Cutibacterium acnes (2%), stem cells (2%), superior capsular reconstruction (2%), bony increased offset reversed shoulder arthroplasty (2%), opioid issues (1%), and tendon transfer (1%). Conclusion The most cited studies from 1900 to 2009 and 2010 to 2019 reported on the rotator cuff and shoulder instability. The most cited articles from 2010 to 2019 reflect the development of shoulder arthroscopy, shoulder arthroplasty, treatment of surgical complications, and augmentation or biologic interventions for rotator cuff repair. Level of evidence Level IV; Review Article

Background There is an increasing need to understand what barriers are present to reduce opioid consumption in orthopedic practice. The purpose of this study was to better understand patient perceptions and understanding of opioid use after shoulder surgery. Methods Eighty-five patients who underwent shoulder surgery anonymously completed a 27-question survey adapted from the Maryland Public Opinion Survey on Opioids with additional demographics. The patients were asked about pain expectations after surgery, use of and access to opioids, opioid perceptions, and information provided regarding safe use, storage, and disposal of opioids. Results When asked about receiving information regarding opioids, only 36% of the patients reported having a conversation with their physician. When asked about appropriate use, 10% agree it is permissible to take more than the recommended dosage of prescription narcotics if they are feeling more pain than usual and 8.5% of the patients reported taking an opioid to get high multiple times in the past year. Furthermore, a majority agreed that opioids may lead to other substance abuse with 76% reporting the risk of harm to be great, and only 55% believing that opioid abuse may lead to overdose or death. Conclusions Surgeons need to be aware that most patients expect to have significant pain after shoulder surgery and expect to be given necessary and continued amounts of opioids. This highlights the need for better counseling and innovative nonopioid pain management protocols. At the institutional level, more effort needs to be made on providing adequate education and disposal mechanisms to help reduce diversion and misuse.

Since the introduction of stemless anatomic shoulder arthroplasty, few midterm functional and radiographic results have been published. This article presents results of the Arthrex Eclipse prosthesis with a mean follow-up of 70 months.We prospectively evaluated the outcome of 53 arthroplasties in 51 patients with a mean age of 65 years at the time of implantation with a minimum follow-up of 48 months. All patients were physically and radiologically examined, and the results documented by Constant-Murley and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.Significant improvements from preoperative to last follow-up were documented in the Constant-Murley score (53.8%-83.5%, P.001) and active range of motion (abduction 84°-108°, flexion 98°-125°, and external rotation 19°-41°). There was no significant difference between total and hemiarthroplasty. The mean DASH score was 28.3 points (95% confidence interval 20.1-35.2). Lowering of bone mineral density was observed in anteroposterior radiographs at the humeral component in 24.5% and at the glenoid component in 33.3%. The rate of complications was 15.7%.This study finds improvements in functional, radiographic, and subjective midterm results comparable to other accessible data for stemless and stemmed arthroplasty.

Background: Shoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis. Methods: The prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed. Results: A total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P

Background Cutibacterium acnes is a common pathogen associated with surgical site infection after shoulder surgery; current standard of care products are largely ineffective at reducing C acnes bacterial burden before surgery. The purpose of this systematic meta-analysis was to assess the efficacy of peroxide-containing solutions (PCS) in decreasing the C acnes burden on the shoulder. Methods This was a systematic review of all level I and II studies investigating the effect of peroxidase-containing products for skin preparation. We extracted data regarding demographics, treatment details and timing, study methodology, and culture positivity. Forest plots were used to determine the pooled efficacy of peroxide solutions versus control. Results Seven studies with 412 patients were eligible for inclusion. Notable heterogeneity was observed in the manner and timing of peroxide application. Two studies applied PCS at the time of surgery; four studies applied PCS in the 24- to 72-hour period leading up to culture acquisition. Compared with the placebo, peroxide significantly diminished C acnes culture positivity (Hazard Ratio 0.174, P = 0.009). When considering using peroxide-containing products in the period leading up to surgery or at the time of surgery, in addition to standard preparation, the addition of peroxide significantly diminished C acnes culture positivity (HR 0.467, P = 0.004). Owing to study heterogeneity, we could not make notable comparisons based on the timing or duration of benzoyl peroxides application. Conclusions Despite heterogeneity in study design, pooled results of high-quality data suggest that the addition of PCS can markedly reduce C acnes bioburden. This review was not able to identify the ideal regimen for the utilization of PCS for reduction of C acnes burden. Level of evidence Level II.

Post-traumatic osteonecrosis of the humeral head has a risk of progression to collapse in absence of treatment. The purpose of this study was to evaluate the results of mesenchymal stem cell grafting of the pre-collapse humeral head (study group) in adult patients with osteonecrosis and to compare the results with a simple core decompression without cells (control group). Patients After inclusion and randomization of 50 patients, 26 patients were enrolled in a single-blinded study for the cell therapy group. Twenty-four other patients were treated with simple core decompression without cells (control group). After a mean of 12-year (range 10 to 15) follow-up, X-ray and MRI were used to evaluate the radiological results, while the Constant score and the visual analog scale were chosen to assess the clinical results. The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow concentration. The average total number of MSCs (counted as the number of colony-forming units-fibroblast) injected in each humeral head was a total injection of average 180,000 ± 35,000 cells (range 74,000 to 460,000). Both the treatment and control groups had a significantly improved clinical score (p

Introduction Musculoskeletal diagnostic ultrasound is an expanding clinical tool and increasingly used at point of care in clinical practice. Criticism around the accuracy of this modality is often attributed to operator dependence. This study evaluated the accuracy of a sonographer’s reporting against shoulder surgery. Methods A musculoskeletal sonographer performed same-day ultrasound scans prior to elective shoulder surgery procedures. The sonographer was blinded to clinical history and previous investigations. A brief physical examination of resisted external rotation and resisted abduction strength was performed prior to scanning. Scan results were reported using British Elbow and Shoulder Society (BESS) reporting criteria. The sonographer attended surgery to gain immediate visual feedback. Sonographic reports and magnetic resonance imaging (MRI) reports were graded (1= complete agreement; 2 = minor discrepancy unlikely to alter patient care; 3 = potentially significant discrepancy; 4 = definite, significant discrepancy) against surgical findings. The accuracy of sonographic reporting was correlated with patients’ body mass index (BMI). Results Fifty-four cases were compared and correlations evaluated. Grade 1 (complete agreement) was reported 87.0% ( n = 47), Grade 2 (minor discrepancy) 9.3% (n = 5) and Grade 3 (potentially significant discrepancy) 3.7% (n = 2). Sonographic reports closely correlated (Grade 1 or 2 scores) with surgical findings in 96% of cases. Conclusions The musculoskeletal sonographic reporting had a high correlation with surgery findings. Ultrasound was more accurate than MRI in reporting full thickness rotator cuff tears. Clinical weakness in resisted external rotation or abduction did not correlate with imaging. Ultrasound was found to be unreliable in detecting rotator cuff tears in participants with a BMI ≥ 35.

Internal rotation contracture of the shoulder is a common sequel of the brachial plexus birth palsy. The purpose of this study is to describe the surgical method used in our centre and to measure the effect of sequentially releasing several anatomical structures that have been ascribed as the cause of the contracture. Twenty-four consecutive patients were operated on with an open release. We documented the increase in passive external rotation after each surgical step. We found small gains in passive external rotation when performing coracoidectomy and division of the upper part of the subscapularis tendon; 4° (95% confidence interval [CI] 2°–6° p Level of evidence: IV

Purpose To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries. Methods Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported. Results The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients. Conclusions CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS. Level of Evidence IV, therapeutic case series.

Background The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes. Methods Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity. Results One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = −0.155, P = .527) or body mass index (r = −0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed. Conclusion The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.

To investigate whether different labels for rotator cuff disease influence people's perceived need for surgery.Randomized controlled experiment.Participants with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomized to 1 of 6 terms describing rotator cuff disease:One thousand three hundred eight (80% of 1626) responses were analyzed. Participants' mean ± SD age was 40.3 ± 16.0 years, and 59% were women. Mean perceived need for surgery (0-10 scale) was low and slightly higher among those assigned to the rotator cuff tear label compared to the bursitis label (2.6 versus 2.1; adjusted mean difference, 0.7; 99.67% CI: 0.0, 1.4). Mean perceived need for imaging (0-10) was moderate and slightly higher among those assigned to the rotator cuff tear (4.7 versus 3.7; adjusted mean difference, 1.0; 99.67% CI: 0.2, 1.9) and subacromial impingement syndrome labels (4.7 versus 3.7; adjusted mean difference, 1.0; 99.7% CI: 0.1, 1.9) compared to the bursitis label.There were small differences in the perceived need for surgery and imaging between some labels, which could be important at the population level.

Background A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery. The use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh) have been used to produce patches. However, clinical evidence on their use is limited. The patch augmented rotator cuff surgery (PARCS) feasibility study aimed to determine the design of a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. Methods A mixed methods feasibility study of conducing a subsequent RCT. The project involved six stages: a systematic review of clinical evidence; a survey of the British Elbow and Shoulder Society’s (BESS) surgical membership; a survey of surgeon trialists; focus groups and interviews with stakeholders; a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. Results The BESS surgeons’ survey identified a variety of patches in use (105 (21%) responses received). Twenty-four surgeons (77%) completed the trialist survey relating to trial design. Four focus groups were conducted involving 24 stakeholders. Twenty-nine (67% of invited) individuals took part in the Delphi. Differing views were held on a number of aspects including the appropriate patient population for trial participation. Agreement on the key research questions and the outline of two potential RCTs were achieved through the Delphi study and the consensus meeting. Conclusions Randomised comparisons of on-lay patch use for completed rotator cuff repairs, and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. The main limitation was that the findings were influenced by the participants, who might not necessarily reflect all stakeholders.

Background Cutibacterium acnes ( C. acnes) is the most common pathogen responsible for post-operative shoulder infections. The purpose of this study was to evaluate the effectiveness of skin preparation methods against C. acnes in shoulder surgery. Methods A systematic review was conducted evaluating the effectiveness of skin preparation methods in the reduction of C. acnes in patients undergoing shoulder surgery. Outcomes were assessed based on the effectiveness of the method used; side effects and cost were also analysed. Results Of the 19 included studies, 9 evaluated pre-surgical home treatments: 8 assessed benzoyl peroxide (BPO) and 6 concluded it is effective in reducing C. acnes. Nine studies assessed surgical skin preparation and concluded that Chlorhexidine gluconate (CHG) was not effective; in contrast hydrogen peroxide reduced C. acnes. Finally, one study evaluated an aseptic protocol using CHG and concluded that it was not effective. Conclusions It was demonstrated that BPO as home treatment is effective in reducing C. acnes load on skin ; it rarely causes side effects and is also cost-effective. This study highlights non-effectiveness of CHG. There was some evidence that the addition of hydrogen peroxide could have a positive effect in the reduction of C. acnes skin load; however, more studies are required.

Blocking the suprascapular nerve under the inferior belly of the omohyoid muscle is a novel regional anesthesia technique that has been proposed for shoulder analgesia. We describe the use of and our experience with bilateral indwelling suprascapular catheters for pain management via continuous infusions in a patient undergoing bilateral shoulder surgery. Bilateral subomohyoid suprascapular catheters were inserted prior to surgery for postoperative analgesia in a patient undergoing bilateral rotator cuff tear repair. The catheters were placed 0.5–1 cm beyond the needle tip, and low local anesthetic infusion rates (ropivacaine 0.2% at 5 mL·hr−1 on each side) were used. Judicious use of preoperatively placed bilateral suprascapular catheters added to a comprehensive multimodal analgesic regimen provided excellent analgesia without respiratory compromise throughout the perioperative course.

Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations.A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (14 seconds considered high fall risk) and 10 Meter Walk test (0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation.Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χBoth patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk.Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Background Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). Methods This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes. Results Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p p p p p Conclusion Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible. Trial registration ClinicalTrials.gov (NCT03657173; September 4, 2018).

The aim of this study is to evaluate the return to sport after surgical treatment of shoulder injuries in professional goalkeepers in relationship with the mechanism of injury and the pattern of related shoulder lesions. Twenty-six shoulders in nineteen elite male professional soccer goalkeepers were retrospectively analyzed considering multiple diseases (instability, rotator cuff, biceps or other tendon injuries). Data was collected for injury modality and context, pathological findings, surgical procedures, time, level of return to sport, and complications. The mechanism of injury was “mild trauma without contact” in 46% of the cases and 54% of injuries happened during training. 11 patients (42%) reported multiple pattern lesions and 9 patients (35%) classic anterior instability lesions. The mean time for return to differentiated training and unrestricted sport activity was 14 and 20.2 weeks, respectively. 15 athletes (62.5%) reported 100% return to sport, 4 (16.7%) to 90%, 1 (4.2%) to 85%, 3 (12.5%) to 80% and 1 athlete to 50%, stopping professional activity. 21% of the cases reported the persistence of some shoulder symptoms. 3 cases experienced a new injury. Patients with classic anterior instability had significantly lower age (30.7 vs 19.8 years, P = 0.001), experienced injury in different context and reported symptoms more frequently compared to multiple lesion patients (4/8 vs 0/10, P = 0.011). Professional elite goalkeepers which required shoulder surgery for different causes demonstrated high-rate level of return to play despite the persistence of mild symptoms. The high frequency of multiple lesions, patients’ characteristics, injury context and mechanism, increase the concern for injuries in overstressed shoulder for this category of sport. IV.

Background The changing of opioids during the transition of care from hospital to home may be associated with harm. Objective To compare patients receiving tapentadol IR versus oxycodone IR following orthopaedic surgery during hospitalisation with regard to the changing of opioids at hospital discharge. Setting A major metropolitan tertiary referral hospital in Australia. Methods This is a retrospective cohort study. Participants included adult orthopaedic surgery patients receiving postoperative tapentadol IR or oxycodone IR during hospitalisation between 1 January 2018 and 30 June 2019. Main outcome measure The proportion of patients for whom the opioid prescribed was changed at hospital discharge. Results The study cohort included 199 patients. Of these, 100 patients received oxycodone and 99 patients received tapentadol post-operatively during hospitalisation. The mean age was 66 years (SD, 12 years) and 111 (56%) were female. The most common surgeries were total knee arthroplasty (91, 46%), total hip arthroplasty (63, 32%) and shoulder surgery (26, 13%). Patients in the tapentadol group were more likely to be changed to a different opioid upon hospital discharge than the oxycodone group (57% versus 9%, difference 48% [95% CI 36–59%, p

Purpose The purpose of this study was to survey the members of North American and European shoulder surgery and sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery. Methods A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can return to play following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return. Results Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to return to play (75.4%). Interestingly, the addition of a remplissage procedure did not affect decision making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to return to play (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to return to play (59.6%). Conclusion Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for RTP after the arthroscopic Bankart repair and Latarjet procedures.

Background The development of acute compartment syndrome (ACS) of the upper extremity after an elective surgical shoulder procedure is rare but can have devastating results. We describe a series of patients who developed ACS of the upper extremity caused by hematoma formation and subsequent upper extremity swelling after undergoing elective surgical shoulder procedures. Methods We retrospectively reviewed the database of our tertiary care institution between 2004 and 2019 to find patients who developed ACS after elective shoulder surgery. We found 4 such patients and reviewed their medical records and extracted data on their history, clinical examination, predisposing factors, treatment, and clinical and radiographic outcomes. Results Of the 4 patients treated, 2 had undergone reverse total shoulder arthroplasty, 1 had undergone open biceps tenodesis, and 1 had undergone closed manipulation for adhesive capsulitis. Two patients developed symptoms of ACS within 24 hours of the index procedure. Both were treated with immediate decompression of the hematoma, and both experienced complete pain relief and full recovery of function at 1-year follow-up. Two patients were on anticoagulation therapy. Of these, 1 patient developed ACS symptoms 14 days after a revision reverse total shoulder arthroplasty and was treated successfully with compartment release. Despite treatment, the other patient developed extensive necrosis of muscles and nerves in the upper extremity and severe neurologic deficits in hand and forearm function. Conclusion ACS of the upper extremity caused by hematoma formation can lead to catastrophic outcomes if diagnosis and treatment are not immediate. Providers should be aware of ACS and the need for prompt diagnosis and treatment.

Background Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. Method The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). Results Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. Conclusion The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.

Background The interscalene brachial plexus block (ISB) is a commonly used nerve block technique for postoperative analgesia in patients undergoing shoulder arthroscopy surgery; however, it is associated with potentially serious complications. The use of suprascapular nerve block (SSNB) has been described as an alternative strategy with fewer reported side effects for shoulder arthroscopy. This review aimed to compare the impact of SSNB and ISB during shoulder arthroscopy surgery. Methods A meta-analysis was conducted to identify relevant randomized controlled trials involving SSNB and ISB during shoulder arthroscopy surgery. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through March 2021. Results We identified 1255 patients assessed in 17 randomized controlled trials. Compared with the ISB group, the SSNB group had higher VAS at rest in PACU (P = 0.003), 1 h after operation (P = 0.005), similar pain score 2 h (P = 0.39), 3-4 h (P = 0.32), 6-8 h after operation (P = 0.05), then lower VAS 12 h after operation (P = 0.00006), and again similar VAS 1 day (P = 0.62) and 2 days after operation (P = 0.70). As for the VAS with movement, the SSNB group had higher pain score in PACU (P = 0.03), similar VAS 4-6 h after operation (P = 0.25), then lower pain score 8-12 h after operation (P = 0.01) and again similar VAS 1 day after operation (P = 0.3) compared with the ISB group. No significant difference was found for oral morphine equivalents use at 24 h (P = 0.35), duration of PACU stay (P = 0.65), the rate of patient satisfaction (P = 0.14) as well as the rate of vomiting (P = 0.56), and local tenderness (P = 0.87). However, the SSNB group had lower rate of block-related complications such as Horner syndrome (P < 0.0001), numb (P = 0.002), dyspnea (P = 0.04), and hoarseness (P = 0.04). Conclusion Our high-level evidence established SSNB as an effective and safe analgesic technique and a clinically attractive alternative to interscalene block with the SSNB’S advantage of similar pain control, morphine use, and less nerve block-related complications during arthroscopic shoulder surgery, especially for severe chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Given our meta-analysis’s relevant possible biases, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.

Introduction There are few studies that compare the cadaver dissections with the medical simulators in means of talent improvement. Therefore, the aim of this study is to find out if using cadaver dissections is still the golden standard for surgical training or using the medical simulators in surgery could replace cadaver dissections. Materials and methods The study is conducted during the European Orthopaedics & Traumatology Education Platform accredited Shoulder Club International Cadaver Course including a number of 34 orthopedics trainees. The participants were randomly divided into two groups to be trained with the simulator (Group 1) and on cadavers (Group 2), followed by a test performed on shoulder arthroscopy simulator (Virtamed ArthroS, Switzerland). There was no conflict of interest before, during, or after the study. Informed consent was obtained from all individual participants included in the study. Results Group 2 had statistically significant higher simulation overview procedure time values than Group 1 (p < 0.05), the meaning of which is participants trained with the simulator completed the given tasks in a shorter period of time. Group 2 had statistically significant higher scratching of humerus cartilage values than Group 1 (p < 0.05), which means that participants trained with simulation have less scratching done on the humerus cartilage than the participants trained on a cadaver. Conclusion To the best of our knowledge, this study is the first one to compare virtual reality (VR) simulators with cadavers for surgical education in an objective manner, while using qualitative and quantitative data. According to this study, it is possible to state that VR simulators are just as effective as cadavers in means of training subjects. As medical education will face a total change all around the world after the COVID-19 pandemic, this study has the potential to be an important guide during and after this period.

To describe the bilateral coracohumeral morphological discrepancy in rotator cuff rupture patients with and without subscapularis (SSC) involvement and to investigate its association with SSC tears. Two hundred and thirteen consecutive patients who were scheduled to have arthroscopic rotator cuff repair were prospectively enrolled in the current study. Patients with acute traumatic rotator cuff rupture, glenohumeral osteoarthritis, bilateral rotator cuff rupture, recurrent shoulder instability, systemic inflammatory disease, and previous shoulder surgery history were excluded. Coracohumeral distance (CHD), coracoid overlap (CO), lesser tuberosity index (LTI) and acromiohumeral interval (AHI) were measured bilaterally using CT scans. Based on arthroscopic findings, patients were included in either the SSC tear group (n = 72) or the control group (n = 141). In the SSC tear group, the affected shoulder possessed a significantly smaller CHD [95% confidence interval (CI) 6.1–7.2 vs. 7.2–8.0 mm, p

Shoulder 36 (Sh-36) is an original quality of life measure for shoulder lesions with high reliability and validity; however, in some cases, especially in those with a Bankart lesion, we observed no improvement in Sh-36 during the postoperative follow-up. Sh-36 may be less effective for a certain shoulder lesion. This study aimed to compare the reliability, validity, and responsiveness of Sh-36 among different representative diagnoses of shoulder lesions.Sh-36 and the Disability of the Arm, Shoulder and Hand (DASH) were measured in 192 patients with a Bankart lesion (Bankart group), rotator cuff tear (Cuff group), and SLAP lesion (SLAP group) who underwent arthroscopic surgery. Both measures were evaluated before surgery, and at 3, 6, 9, 12, 18, and 24 months postoperatively, and reliability, validity, and responsiveness of Sh-36 and the DASH were compared among the three groups.Significant postoperative improvement was observed in the three groups (p 0.0001) within 9 months. No marked improvement was observed after 9 months in the Bankart and SLAP groups due to the ceiling effect; however, most domains of Sh-36 increased continuously in the Cuff group during the whole follow-up period. Reliability and construct validity were sufficient in all the groups. The longitudinal validity was sufficient in most domains for the three groups; however, the standardized response mean in the Bankart group was lower than that in other two groups, indicating low responsiveness in this group because of the ceiling effect.Sh-36 was a valid and reliable instrument in patients who have undergone arthroscopic shoulder surgery, especially for patient with a rotator cuff tear with high responsiveness. However, Sh-36 had lower standard response mean representing lower responsiveness in the Bankart group due to the ceiling effect and may not be ideal for longitudinal follow-up in patients with a Bankart lesion.

Background There is currently disagreement among experts in the field of shoulder surgery when attempting to define the term “pseudoparalysis.” Multiple surgical techniques to address this condition have been investigated; however, many studies have recruited heterogeneous patient populations and have used varying definitions of pseudoparalysis. This makes it difficult to compare outcomes among various techniques. To our knowledge, no previous study has surveyed international experts regarding the definition of pseudoparalysis using a questionnaire and video-based patient assessment. The purpose of this study was to evaluate the level of agreement among shoulder surgeons in defining and applying the term “pseudoparalysis.” We hypothesized that inter-rater agreement for classifying patients as having pseudoparalysis would be poor. Methods Members of the American Shoulder and Elbow Surgeons, the European Society for Surgery of the Shoulder and the Elbow, and our national shoulder and elbow society were surveyed on 2 occasions using an electronic questionnaire. All surgeons were asked to identify their preferred definition of pseudoparalysis from 1 of 4 options. The surgeons then viewed video examinations of 10 patients and labeled them as having pseudoparalysis or not. Inter-rater reliability and intrarater reliability were calculated as κ coefficients. The Pearson χ2 test was used to detect associations between the preferred definition and demographic information. Results A total of 246 surgeons responded to at least 1 survey. Overall inter-rater agreement on classifying patients as having pseudoparalysis based on video consultation showed a κ value of 0.59 (95% confidence interval [CI], 0.58-0.60). The same verbal definition was selected by 56.1% of surgeons. The surgeons were not internally consistent in their choice of definition, with intrarater reliability showing a κ value of 0.64 (95% CI, 0.48-0.81). Intrarater reliability for classifying patients as having pseudoparalysis was better, with a κ value of 0.78 (95% CI, 0.72-0.83). An association was observed between how surgeons defined pseudoparalysis and their age (P = .03), as well as their shoulder caseload percentage (P = .04). Conclusion Shoulder surgeons do not agree on how best to define pseudoparalysis of the shoulder. Inter-rater agreement based on video consultation was weak overall and improved with the elimination of an outlier video. Intrarater agreement was less frequent when selecting a preferred definition compared with classifying patients as having pseudoparalysis based on video examinations. Surgeons may rely less on explicit criteria and more on a conceptual framework when assigning a “pseudoparalytic” label. Care should be taken with use of the term “pseudoparalysis” in clinical outcome studies when there is clearly a lack of consensus among experts in defining this term.

Background Elective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty. Methods We identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain. Results Of the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P Conclusion About 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty. Level of evidence Level III; Cohort Study with Prospective Data and Retrospective Study Design.

Background The patient acceptable symptomatic state (PASS) represents clinical improvement following surgery that patients deem as satisfactory; however, thresholds for achieving this clinical benchmark have not yet been established beyond 1 year following primary and reverse shoulder arthroplasty. Methods A prospectively maintained registry was retrospectively queried for patients undergoing either a primary TSA or RTSA at a single institution between November, 2015 and October, 2017. All patients completed the ASES, SANE, and Constant patient-reported outcome (PRO) scores at the 2-year time point. PASS threshold scores were calculated using anchor-based methodology with subsequent calculation of achievement rates. Multivariate logistic regression was used to identify demographic and clinical variables associated with the likelihood of PASS achievement. Results A total of 93 TSA (mean age 61.4 ± 8.5 years, 32.3% female) and 111 RTSA (mean age 70.0 ± 8.1 years, 51.4% female) patients met final inclusion criteria. One-hundred sixty-five patients (80.8%) responded to the binary anchor question as “satisfied” regarding their surgical outcome. The PASS cutoffs for ASES, SANE, and Constant were 81.7, 85.7, and 24.0, respectively (AUC > 80%), with PASS achievement rates ranging from 50.7% to 59.9% for the entire study population and 66.7% to 83.3% for a risk-stratified subgroup. Patients undergoing TSA had a significantly higher PASS achievement rate relative to RTSA (P = .010) for ASES. Independent risk factors for decreased PASS achievement included lower preoperative PRO score, prior shoulder surgery, sedentary lifestyle, smoking, workers’ compensation status, and diabetes mellitus (DM). Conclusion The majority of patients reach the PASS benchmark by 2 years after shoulder arthroplasty, with an optimal subgroup of risk-stratified patients achieving PASS at a rate greater than 80% for ASES. Patients undergoing TSA have a higher likelihood of reaching the PASS than patients undergoing RTSA, independent of other variables. Lower baseline outcome scores, prior shoulder surgery, smoking, and sedentary lifestyle are associated with lower PASS rates after TSA. Worker's compensation status and comorbid DM are predictive of reduced PASS rates after RTSA. Primary diagnosis and glenoid morphology did not have a significant impact on the rate of achieving the PASS. This information is valuable for patient selection and counseling prior to shoulder arthroplasty. Level of Evidence Level III; Prognostic Study; Retrospective Case Series.

Background: Numerous studies show that patients who failed conservative management, benefit from open, mini open and arthroscopic rotator cuff repair (ARCR). However, there is a paucity of literature addressing ARCR and outcomes in patients older than the age of 75 years. The purpose of our study was to compare the outcomes of ARCR in patients older than 75 years and younger than 75 years of age. Methods: Between January 2010 and December 2016, 397 patients underwent unilateral ARCR; of which, 23 patients were 75 years of age and older. Outcome measures recorded include the Constant Shoulder Score (CSS), University of California, Los Angeles Shoulder Score (UCLASS), Oxford Shoulder Score (OSS), and visual analog scale (VAS) for pain assessment. Results: There were no statistically significant differences in VAS, CSS, and UCLASS between the two groups at all time points of follow-up (all P > .05). At 2 years after surgery, the OSS was 2 ± 5 points better in the

Background Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. Questions/purposes In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? Methods Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. Results In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. Conclusion In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. Level of evidence Level IV, therapeutic study.

Background Shoulder surgery results in several months of rehabilitation, which is often underestimated by patients preoperatively. Currently, there is little written about this process of recovery. Information on this would help patients to anticipate the trajectory of their recovery. This would also provide a reference point allowing surgeons to compare a patient's progress in their recovery. The purpose of our study was to analyze and document the expected rate of recovery for the most common shoulder operations. Methods A retrospective analysis of all patients who underwent total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), arthroscopic rotator cuff repair (ARCR), and arthroscopic biceps tenodesis (BT) using prospectively collected data from the Surgical Outcomes System registry was performed. All patients included had a complete 2-year follow-up data set. The pain score (visual analog scale) was measured preoperatively at 2, 6, and 12 weeks and 6, 12, and 24 months. The American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) score were recorded preoperatively and after 6, 12, and 24 months. The speed of recovery, defined as the percentage of total improvement, for each procedure was assessed as the primary outcome parameter at all time points. Results All shoulder interventions resulted in significant improvement of the pain, SANE, and ASES scores 2 years after shoulder surgery. The speed of recovery of all 3 scores was highest after TSA at all measured time points and slowest after ARCR and BT. Measured by the pain score, 90% and 82% of the total improvement after TSA and RTSA was completed after 6 weeks compared to 58% and 59% after ARCR and BT, respectively. Six months postoperatively the ASES recovery rate was significantly higher after arthroplasty (TSA 96% and RTSA 85%) compared to ARCR and BT (76% and 77%, respectively). The SANE score recovery rate was between 82% and 92% (TSA 92%, RTSA 89%, ARCR 87%, BT 82%) 6 months after surgery. After 1 year all patient groups reached 89% or more of the total improvement in all scores, except for the pain after ARCR (89%). Conclusion The improvement in pain is fastest after TSA and slowest after ARCR and BT. After TSA and RTSA, >80% of the total pain reduction is achieved 6 weeks postoperatively, whereas after ARCR and BT, >80% of the pain reduction is achieved only 6 months postoperatively. At 12 months postoperatively, the differences in recovery curves were not significant.

Introduction The role of telemedicine is rapidly evolving across medical specialties and orthopaedics. The utility of telemedicine to identify operative candidates and determine surgical plans has yet to be demonstrated. We sought to assess whether surgical plans proposed following telemedicine visits changed after subsequent in-person interaction across orthopaedic subspecialties. Materials and methods We identified all elective telemedicine encounters across two academic institutions from March 1, 2020 to July 31, 2020. We identified patients indicated for surgery with a specific surgical plan during the virtual visit. The surgical plans delineated during the telemedicine encounter were then compared to final pre-operative plans documented following subsequent in-person evaluation. Changes in the surgical plan between telemedicine and in-person encounters were defined using a standardised schema. Regression analysis was used to evaluate factors associated with a change in surgical plan between visits across specialties, including the number of virtual examination manoeuvres performed. Results We identified 303 instances of a patient being indicated for orthopaedic surgery during a telemedicine encounter. In 11 cases (4%), the plan was changed between telemedicine and subsequent in-person encounter. No plans were changed amongst patients indicated for joint arthroplasty and foot and ankle surgery, whilst 4% of plans were changed amongst sports surgery and upper extremity/shoulder surgery. Surgical plans had the highest rate of change amongst spine surgery patients (8%). There was notable variability in the conduct of virtual examinations across subspecialties. Conclusion Our results demonstrate the capability of telemedicine to support development of accurate surgical plans for orthopaedic patients across several subspecialties. Our findings also highlight the substantial variation in the utilisation of physical examination manoeuvres conducted via telemedicine across institutions, subspecialties, and providers. Description of study type Level IV, retrospective cohort study.