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Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs.A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the IThe initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P.001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P.001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P.001).When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use.A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the IThe initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P.001 for 4 and 8 hours) or local ropivacaine injection (P.001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot interscalene block (ssISB). No differences in opioid use (at P.05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection.Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot interscalene blocks are optimal for reducing early postoperative pain (24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.

Objective To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93–0.95]; p Conclusion The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant.The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P.001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin.Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin.III, systematic review of level III studies.

To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin. A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique. Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5 years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5 mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%). This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5 years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking. IV.

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

Background: Abnormal scaphoid alignment after fracture is used as an indication for fixation. Acceptable alignment after reduction and fixation of scaphoid fractures is not well defined. We systematically reviewed the literature to identify how scaphoid malunion is currently defined and by what parameters. Methods: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were searched for studies published in the English language that reported on outcomes after scaphoid malunion and included measurements to define malunions. Radiographic scaphoid measurement parameters were collected. Clinical outcome measures recorded included grip strength, wrist range of motion, and patient-reported outcome measures. Study quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Descriptive summaries of the studies are presented. Results: The initial search yielded 1600 articles. Ten articles (161 participants, 93% males, mean age = 28.3 + 6.3 years, mean MINORS score = 10.2 + 1.6) were included and analyzed. Scaphoid malunion was defined if the lateral intrascaphoid angle (LISA) was >45° (3 articles), LISA >35° (1 article), and height to length ratio >0.6 (3 articles). Four out of 5 studies found no significant associations between patient outcomes and degree of scaphoid malunion measured on imaging. Conclusions: There is a lack of consensus for defining scaphoid malunion on imaging and absence of correlation between findings on imaging and patient outcomes. Future studies defining scaphoid malunion should be appropriately powered, incorporate measures of intrarater and interrater reliabilities for all reported imaging measurements, and utilize validated patient-reported outcome measures to reflect that malunion is associated with inferior outcomes meaningful to patients.

Background The purpose of this study was to determine whether patients undergoing any shoulder arthroscopic procedure with concomitant biceps tenodesis have higher reoperation and complication rates vs. patients undergoing shoulder arthroscopy without concomitant biceps tenodesis. Methods A large database was queried for patients undergoing shoulder arthroscopy, identified by Current Procedural Terminology code. Only records indicating the laterality of the procedure were included. Patients were divided into 3 cohorts: arthroscopic shoulder surgery without concomitant biceps tenodesis (group 1), surgery with arthroscopic biceps tenodesis (group 2), and surgery with open biceps tenodesis (group 3). Reoperations on the same shoulder, as well as medical or surgical complications (by International Classification of Diseases, Ninth Revision code) during the 30-day postoperative period, were determined. Multivariate logistic regression was used to control for differences in age, sex, and Charlson Comorbidity Index between groups. Results We identified 62,461 patients (54.3% male patients) in the database who underwent shoulder arthroscopy, with 51,773 patients in group 1, 7134 patients in group 2, and 3554 patients in group 3. Overall, 3134 patients (5.0%) underwent a shoulder arthroscopy reoperation. With adjustment for age, sex, and Charlson Comorbidity Index, the biceps intervention groups demonstrated a significantly higher overall reoperation rate (odds ratio, 1.3 [95% confidence interval, 1.2-1.5]; P < .001). Patients undergoing biceps tenodesis had a lower adjusted overall 30-day complication rate vs. those not undergoing tenodesis (odds ratio, 0.82 [95% confidence interval, 0.79-0.86]; P < .001). Conclusion Reoperation rates were significantly higher in patients undergoing shoulder arthroscopy with biceps tenodesis than in patients undergoing shoulder arthroscopy without biceps tenodesis. Both the arthroscopic and open tenodesis groups had significantly lower complication rates.

Uvular necrosis is a rare postoperative complication that can manifest from endotracheal tube intubation or laryngeal mask airway placement resulting in compression and restriction of blood flow to the uvula. This report describes three patients who underwent outpatient shoulder surgery under general anesthesia and were subsequently diagnosed with uvular necrosis. Their symptoms included persistent sore throat, dysphagia, odynophagia, and foreign body sensation, with swelling and white exudate on the uvular tip. All three patients were treated conservatively and had complete symptom resolution. While symptoms from uvular necrosis typically self-resolve within two weeks, it is important to recognize the condition and risk factors because patients may benefit from reassurance and conservative treatment.

Background:The teres minor is a critical component of the rotator cuff and serves as one of the few external rotators of the humerus. Information is lacking regarding the effect of teres minor atrophy in isolation and in the setting of concomitant full-thickness rotator cuff tears on outcomes in patients undergoing rotator cuff surgery.Purpose:To investigate the effect of preoperative teres minor fatty infiltration on postoperative clinical outcomes in patients with and without full-thickness rotator cuff pathology.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of patients undergoing primary arthroscopic shoulder surgery between 2014 and 2016 was performed. Preoperative magnetic resonance imaging was used to determine fatty infiltration for each rotator cuff muscle using the modified Goutallier classification. American Shoulder and Elbow Surgeons (ASES) as well as the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained preoperatively and during follow-up. Exclusion criteria included prior surgery on the ipsilateral shoulder or a diagnosis of inflammatory arthropathy. For analysis, patients were dichotomized to grade 0 or grade 1-4 atrophy of the teres minor as well as to full-thickness or partial-thickness rotator cuff pathology.Results:A total of 36 of 47 (76.6%) patients (mean age, 63 years; range, 45-76 years) were available for postoperative follow-up at a mean of 40 months (range, 30-48 months). Postoperative ASES score was significantly higher and QuickDASH score was significantly lower among all patients in the grade 0 group compared with the grade 1-4 group. Postoperative ASES and QuickDASH scores were not significantly different in patients with partial-thickness rotator cuff tears at any time point. However, the postoperative ASES score was significantly higher and QuickDASH score was significantly lower in the grade 0 versus grade 1-4 group for patients with full-thickness rotator cuff pathology.Conclusion:Preoperative teres minor atrophy in patients undergoing surgery for rotator cuff pathology may impair postoperative clinical outcomes, especially in patients with full-thickness tears.

Purpose To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings. Methods A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis. Results The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all). Conclusion Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row. Level of Evidence Level IV, systematic review of Level II-IV studies.

Background: Active patients with musculoskeletal pain are not immune to psychological or psychiatric disease. Observations suggest that patients undergoing hip arthroscopic surgery may have an increased prevalence of comorbid psychiatric conditions. Hypothesis: Patients undergoing hip arthroscopic surgery have an increased prevalence of concomitant psychiatric diagnoses compared with the general population as well as those undergoing anterior cruciate ligament (ACL) reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review of a medical claims database spanning from 2007 to 2016 was utilized to identify patients with a Current Procedural Terminology (CPT) code indicating that they had undergone hip arthroscopic surgery. This group was then dichotomized to those with or without an International Classification of Diseases, 9th Revision (ICD-9) and 10th Revision (ICD-10) diagnosis code indicating a psychological or psychiatric condition at any time before hip arthroscopic surgery or up to 2 years after hip arthrscopic surgery. As a control, ICD-9 and ICD-10 diagnosis codes for psychological or psychiatric conditions were determined in patients without a CPT code for hip arthroscopic surgery (general population) as well as for 2 surgical groups: those undergoing ACL reconstruction and those undergoing shoulder stabilization surgery. Prevalence was determined in all groups and compared using chi-square analysis. Results: There were 22,676,069 patients in the database, with 2428 undergoing hip arthroscopic surgery. Those undergoing hip arthroscopic surgery had a 3-fold increased prevalence of concomitant psychiatric diagnoses compared with the general population (52% vs 17%, respectively; P < .0001). There was a significant difference in the prevalence of psychiatric diagnoses in the hip arthroscopic surgery group between male and female patients (46% vs 56%, respectively; P = .0061), with depression and anxiety being the 2 most common comorbid conditions. Those undergoing hip arthroscopic surgery also had a significantly increased prevalence of concomitant psychiatric diagnoses versus those undergoing ACL reconstruction (52% vs 28%, respectively; P < .0001) as well as those undergoing shoulder stabilization surgery (52% vs 42%, respectively; P < .0001). Conclusion: Patients undergoing hip arthroscopic surgery had an increased prevalence of comorbid psychiatric conditions compared with the general population as well as those undergoing ACL reconstruction or shoulder stabilization surgery. Depression and anxiety were the most prevalent concomitant psychiatric diagnoses.

Fixation of full-thickness subscapularis tears requires secure fixation for adequate healing. Because of this, a double-row construct is utilized by the senior author for all full-thickness subscapularis tears. This technique typically requires an additional anterosuperolateral portal for tendon mobilization, coracoplasty, as well as suture management. A double-row knotless repair is described; however there is no evidence of superiority for knotless over traditional knot-tying techniques.

Traditional subscapularis repair has been an open procedure, but arthroscopic techniques are increasingly common for repair because they allow the surgeon to address concomitant pathology while still providing adequate mobilization and secure fixation of the torn tendon. This chapter describes the mobilization and fixation of both partial and full-thickness subscapularis tears from the intra-articular space.