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Aims The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. Methods Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. Results A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. Conclusion Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554.

This cross-sectional study uses data from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System to assess trends in the prevalence of electric scooter injuries in the US from 2014 to 2019.

INTRODUCTION The proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft-prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies. METHODS A total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10). RESULTS Reverse reconstructions had improved forward elevation (85° vs. 44°, p

PURPOSE OF THE REVIEW: Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure. RECENT FINDINGS: The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. SUMMARY: The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.

The purpose of this study is to analyze the outcomes of open and arthroscopic capsular release following total shoulder arthroplasty.Over 15 years, 19 patients experienced persistent shoulder stiffness after anatomic total shoulder arthroplasty refractory to nonoperative treatment, requiring either open (n = 5) or arthroscopic (n = 14) capsular release. There were seven (39%) patients who had a prior diagnosis of stiffness before the primary arthroplasty.At a follow-up of 2.3 years (1-5.5), there were changes in range of motion, including forward flexion (77°-117°), abduction (49°-98°), external rotation (9°-19°), internal rotation at 0° (Sacrum to L1), and pain (4.1-2.3) scores (p 0.01). There were seven (37%) patients that required a reoperation following the initial capsular release. The survival-free of reoperation at 2 and 5 years was 76% and 53%, respectively, while the survival-free of revision surgery at 2 and 5 years was 83%. Furthermore, three (16%) patients required a repeat capsular release. Overall, there were 11 (58%) complications, including stiffness (n = 9), infection (n = 1), subscapularis rupture (n = 2), glenoid loosening (n = 3), and pain with weakness requiring reoperation (n = 1).Shoulder stiffness after total shoulder arthroplasty is a very difficult pathology to treat, with high rates of complications and reoperations after capsular release. Overall, in patients that do not develop glenoid loosening, capsular release does improve the patient's pain and shoulder motion. Furthermore, when patients develop stiffness, it is critical to rule out other etiologies, such as glenoid loosening, prior to proceeding with capsular release.Retrospective case series.

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship.The Truven Marketscan claims database was used to identify patients who underwent primary, unilateral TSA. Preoperative opioid use status was then used to divide patients into cohorts based on the average daily oral morphine equivalents (OMEs) received in the 6-month preoperative period. This included the following cohorts: opioid naïve and1, 1-5, 5-10, and10 average daily OMEs. In total, 29,454 patients with 90-day postoperative follow-up were included. Of these, 21,580 patients and 8959 patients had 1- and 3-year follow-up, respectively. Patient information and complication data were collected. Univariate and multivariate logistic regression were then performed to assess the association of preoperative opioid use with postoperative outcomes. A subgroup analysis was performed to examine revision surgery at 1 and 3 years postoperatively.Forty-four percent of identified patients received preoperative opioids, but the preoperative opioid-naïve patient became more common over the study period. Multivariate analysis demonstrated that patients receiving10 average daily OMEs (compared with opioid naïve) had higher odds of opioid overdose (odds ratio [OR] 4.17, 95% confidence interval [CI] 1.57-11.08, P = .004), wound complication (OR 2.04, 95% CI 1.44-2.89, P.001), superficial surgical site infection (OR 2.33, 95% CI 1.63-3.34, P.001), prosthetic joint infection (OR 3.41, 95% CI 2.50-4.67, P.001), pneumonia (OR 1.95, 95% CI 1.39-2.75, P.001), and thromboembolic event (OR 1.42, 95% CI 1.18-1.72, P.001). The same group had higher health care utilization, including extended length of stay, nonhome discharge, readmission, and emergency department visits (P ≤ .001). Total perioperative adjusted costs were more than $7000 higher in the10-OME group when compared to preoperative opioid-naïve patients.Opioid use prior to TSA is common and is associated with increased complications, health care utilization, revision surgery, and costs. This risk is dose dependent, and efforts should be made at cessation prior to surgery.

Surgical treatment of wrist arthritis in the younger patient population remains a challenging issue, and various surgical options need to be carefully considered for each patient. Proximal row carpectomy and 4-corner arthrodesis have proven to be reliable options for reducing pain and restoring adequate function in most young high-demand patients if the lunate facet is spared. Selective neurectomy has proven to be a promising stand-alone or complementary procedure for the treatment of pain that is associated with wrist arthritis in patients of all ages, with spared motion and the opportunity to perform additional procedures if pain continues. Alternative procedures, including capitolunate arthrodesis, total wrist arthrodesis, radial styloidectomy, total wrist arthroplasty, and wrist hemiarthroplasty, have considerable strengths and weaknesses and need to be studied further in younger patients.

The Tikhoff-Linberg procedure is a limb salvage technique for tumours of the shoulder girdle which preserves function of the hand and elbow; however, shoulder function is limited. A humeral cap endoprosthesis (Stryker Orthopedics, Mahwah, NJ, USA) was developed within the Modular Replacement System (MRS) to act as a functional spacer for these defects; however, the outcomes of this implant have not been described.Thirty-three (17 male, 16 female) patients underwent a Tikhoff-Linberg procedure at our institution. Of these, 17 (11 females, 6 males) were reconstructed with a MRS humerus endoprosthesis. Outcomes and complications were compared between patients who were reconstructed (n = 17) and those who were not (n = 16).Complications occurred in 14 (42%) patients, with more complications in patients who were reconstructed (n = 11, 65% vs. n = 3, 19%, p = 0.01). Endoprosthetic complications included stress shielding of the bone/prosthesis interface (n = 7, 41%) and subluxation/instability (n = 5, 29%), leading to a revision surgery in two (12%). Post-operatively, the mean Musculoskeletal Tumor Society Score (MSTS93) was 67 ± 11%, with no difference in the mean MSTS93 between patients who were reconstructed and those who were not (67 ± 10% vs. 68 ± 12%, p = 0.77).Reconstruction with a MRS humerus cap endoprosthesis resulted in a high rate of complications following a Tikhoff-Linberg procedure. Stress shielding and subluxation were common, and as such, the use of this prosthesis is limited to cases where a standard implant is not a feasible option.

It is widely believed that structured rehabilitation programs by professional therapists help guide patients through the various recovery periods after shoulder arthroplasty, speeding up their recovery and improving their final functional gains. However, to our knowledge, there are no studies providing information about the current state of physical rehabilitation use after shoulder arthroplasty.To describe the variation in physical rehabilitation utilization after total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), and to identify differences in utilization based on type of insurance (private versus public), sex, age, and region of the country.This epidemiological retrospective database study utilized a commercially available database, PearlDiver, with longitudinal patient tracking linking all patients' Current Procedural Terminology and International Classification of Diseases-Ninth Revision codes to their specific records to analyze patterns of physical rehabilitation usage after TSA and RSA in the United States. Two main patient populations were analyzed within the PearlDiver database, the Humana private insurance population and the Medicare insurance population. The period analyzed was 2010 to 2015.There was significantly higher utilization of physical rehabilitation in the Humana population when compared to the Medicare population (P.001, Cramer's V = 0.270). In the Humana population, 36% of patients had 5 or fewer physical rehabilitation visits in the 6 months following their operation, while in the Medicare population, 56% of patients had 5 or fewer physical rehabilitation visits in the same period. Those with TSA had a higher utilization rate than those with RSA in the Humana (P.001, V = 0.104; TSA, 31% had 5 or fewer physical rehabilitation visits; RSA, 40% had 5 or fewer physical rehabilitation visits within 6 months) and Medicare populations (P.001, V = 0.135; TSA, 51% had 5 or fewer physical rehabilitation visits; RSA, 61% had 5 or fewer physical rehabilitation visits within 6 months).Postoperative utilization of physical rehabilitation after anatomic TSA and RSA is markedly higher in privately insured patients than in patients with Medicare, regardless of age, sex, diagnosis, or region of country. These findings have important implications, from the individual patient's experience and outcomes to system-wide resource utilization.Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(11):856-863. Epub 8 May 2018. doi:10.2519/jospt.2018.8176.

Aims Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98.

BACKGROUND The vertical rectus abdominis myocutaneous flap has been used to reliably reconstruct posterior soft-tissue defects following resection of high sacral tumors, providing skin and soft-tissue bulk. Current literature examining the use of these flaps for high sacral reconstruction is limited. The purpose of this study was to report the authors' institution's outcome on the use of the vertical rectus abdominis myocutaneous flap to reconstruct a high sacral defect following an oncologic resection. METHODS Eighty-seven patients (29 female and 58 male) underwent vertical rectus abdominis myocutaneous flap surgery to reconstruct a posterior wound following high sacral tumor resection from 1994 to 2016. The mean age and body mass index were 52 years and 27.8 kg/m(2), respectively. The mean follow-up was 6 years. RESULTS Sixty-eight patients (79 percent) sustained a complication, most commonly a wound complication [n = 41 (47 percent)]. Twenty patients (23 percent) sustained a donor-site wound complication, most commonly a wound dehiscence (n = 10). Complications resulted in a reoperation in 44 patients (51 percent), with total flap failure occurring in one (1 percent). Preoperative radiotherapy and obesity were found to increase the risk of wound complications (p = 0.004 and p = 0.02, respectively) and deep infection (p = 0.03 and p = 0.02, respectively). CONCLUSIONS Complications were common following vertical rectus abdominis myocutaneous flap surgery; however, total flap loss was not. Patients with obesity and preoperative radiotherapy should be cautioned on their increased risk of complications. Currently, the vertical rectus abdominis myocutaneous flap is the authors' preferred means of soft-tissue reconstruction following high sacral tumor resection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Purpose The purpose of this study was to examine the medium-term outcomes of patients undergoing proximal interphalangeal (PIP) joint arthroplasty using a pyrocarbon implant. Methods The study comprised an analysis of 170 PIP joint pyrocarbon arthroplasties in 99 patients with a minimum 2-year clinical follow-up. Diagnoses included inflammatory arthritis (n = 49), posttraumatic arthritis (n = 29), and osteoarthritis (n = 92). Univariate logistic regression and Kaplan-Meier survival analyses were performed. Results At an average follow-up of 6 years (range, 2–14 years), 58 reoperations (34%) were required, including 36 (21%) involving implant revision surgery. The majority of revisions were performed for either dislocations (n = 16) or pain and stiffness (n = 14). The 5- and 10-year survival-free of revision surgery rates were 79% and 77%, respectively. The risk for revision surgery was higher in patients with posttraumatic arthritis. There were 15 intraoperative complications involving a fracture and 26 postoperative complications, including 21 dislocations. In unrevised implants, patients had significant improvements in their preoperative to postoperative pain levels, with no change in their PIP joint total arc of motion. At a mean radiographic follow-up of 5.4 years, there were 28% with grade 3+ loosening and 36% with progressive implant instability. Implant loosening or progressive instability was not associated with worse pain or PIP joint total arc of motion. Conclusions Approximately 1 in 5 PIP joint arthroplasties with a pyrocarbon implant will require revision surgery by 5 years, and 1 in 3 will undergo more than 1 operation. Furthermore, 1 in 4 PIP joint arthroplasties will have grade 3+ radiographic loosening and 1 in 3 will have progressive loosening or subsidence by 5 years. These results are particularly concerning in young patients and those with posttraumatic arthritis. Overall, in patients that do not require revision surgery, pain relief was improved and motion maintained. Type of study/level of evidence Therapeutic IV.

An analysis was conducted of 325 consecutive metacarpophalangeal arthroplasties prospectively collected using a single institution’s total joints registry over a 14-year time period to characterize long-term radiographic and functional outcomes. Patients were followed for a mean of 7.2 years (2–18) or until revision. The 5-, 10- and 15-year survival free from revision were 98%, 95% and 95%, respectively. The 5-, 10- and 15-year survival rates free from radiographic implant fracture were 93%, 58% and 35%, respectively. The 5-, 10- and 15-year survival rates free from coronal plane deformity greater than 10° were 81%, 37% and 17%, respectively. Patients had significant improvements in their postoperative pain levels and metacarpophalangeal arc of motion. Neither implant fracture, nor coronal plane deformity >10° had a significant association with worse function. Overall, pain relief and functional improvement are reliable, though silicone implants do not protect from progression of coronal plane deformity and have a high fracture rate. Level of evidence: IV

Studies have demonstrated mixed results after humeral head replacement (HHR) for osteoarthritis at short- and medium-term follow-up intervals. The purpose of this study was to investigate the long-term outcomes (minimum 10 years) of HHR for the treatment of osteoarthritis.This study included 44 shoulders in 42 patients who had been followed up for a minimum of 10 years, at a mean clinical follow-up of 17 years (range, 10-30 years). Of this group, 31 shoulders had radiographic follow-up beyond 5 years, at a mean of 11.1 years (range, 5-21 years).Patients experienced significant pain relief postoperatively that was maintained during the long-term follow-up (P .01), with a subgroup of 11 patients reporting persistent moderate or severe pain. Patients maintained increases in shoulder abduction (.01), external rotation (.01) and modified Neer scores (.01). Ten of 44 (22.7%) shoulders underwent revision surgery, predominantly for glenoid arthrosis (n = 9). In the 25 shoulders with 5 years of radiographic follow-up, Kaplan-Meier survival analysis demonstrated moderate to severe glenoid erosion in 50% at 5 years, which increased to 59% at 15 years and 88% at 20 years.HHR remains a successful operation for osteoarthritis at long-term follow-up. However, there is a substantive subgroup with continuing pain and a high rate of glenoid bone erosion after 10 years. Surgeons should carefully consider patients' needs and desires when judging the indications for HHR.

Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis.Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients.All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes.Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation. Four portals are used: a posterior standard portal and 3 anterior portals, all lateral to the conjoint tendon. The anterior rim of the glenoid and the coracoid process are prepared. Two holes are drilled in the glenoid and in the coracoid process with 2 specific guides. The subscapularis is then split, and 2 cortical buttons are passed from posterior to anterior through the tunnels with a shuttle relay. The coracoid process undergoes osteotomy and is guided through the split in the subscapularis to the anteroinferior rim of the glenoid by pulling on the cortical buttons.

We retrospectively reviewed and compared the outcomes and complications associated with 81 single digit and 168 multi-digit proximal interphalangeal joint arthroplasties performed from 1998 to 2012 in 136 patients. Clinical outcomes were assessed with an average follow-up of 5.3 years for single digit and 5.9 years for multi-digit proximal interphalangeal joint arthroplasty. Comparing single versus multi-digit proximal interphalangeal joint arthroplasty, the reoperation-free survival was 67% and 68% at 5 years and 56% and 67% at 10 years, respectively. Furthermore, in comparison of single versus multi-digit proximal interphalangeal joint arthroplasty, the revision-free survival was 80% and 86% at 5 years and 80% and 85% at 10 years, respectively. Given the similar, or even slightly improved, rates of complications, reoperation, and revision surgery, proximal interphalangeal joint arthroplasty performed on multi-digits results in no worse outcomes compared with single digit proximal interphalangeal joint arthroplasty. Level of evidence: IV

Revascularization of natural and synthetic scaffolds is a critical part of the scaffold's incorporation and tissue ingrowth. Our goals were to create a biocompatible polymer scaffold with 3D-printing technology, capable of sustaining vascularization and tissue ingrowth.We synthesized biodegradable polycaprolactone fumarate (PCLF) scaffolds to allow tissue ingrowth via large interconnected pores. The scaffolds were prepared with Poly(lactic-co-glycolic acid)(PLGA) microspheres seeded with or without different growth factors including VEGF,FGF-2, and/or BMP-2. Scaffolds were implanted into the subcutaneous tissues of rats before undergoing histologic and microCT angiographic analysis.At harvest after 12 weeks, scaffolds had tissue infiltrating into their pores without signs of scar tissue formation, fibrous capsule formation, or immune responses against PCLF. Histology for M1/M2 macrophage phenotypes confirmed that there were no overt signs of immune responses. Both microCT angiography and histologic analysis demonstrated marked tissue and vessel ingrowth throughout the pores traversing the body of the scaffolds. Scaffolds seeded with microspheres containing VEGF or VEGF with either BMP-2 or FGF-2 had significantly higher vascular ingrowth and vessel penetration than controls. All VEGF-augmented scaffolds were positive for Factor-VIII and exhibited collagen tissue infiltration throughout the pores. Furthermore, scaffolds with VEGF and BMP-2 had high levels of mineral deposition throughout the scaffold that are attributable to BMP-2.PCLF polymer scaffold can be utilized as a framework for vascular ingrowth and regeneration of multiple types of tissues. This novel scaffold material has promise in tissue regeneration across all types of tissues from soft tissue to bone.

PURPOSE: The poor healing potential of intra-articular ligament injuries drives a need for the development of novel, viable ‘neo-ligament’ alternatives. Ex vivo approaches combining stem cell engineering, 3-dimensional biocompatible scaffold design and enhancement of biological and biomechanical functionality via the introduction of key growth factors and morphogens, represent a promising solution to ligament regeneration. METHODS: We investigated growth, differentiation and extracellular matrix (ECM) protein production of human adipose-derived mesenchymal stem/stromal cells (MSCs), cultured in 5% human platelet lysate (PL) and seeded on three-dimensional polycaprolactone (PCL) scaffolds, in response to the connective-tissue related ligands fibroblast growth factor 2 (basic) (FGF2) and growth and differentiation factor-5 (GDF5). Phenotypic alterations of MSCs under different biological conditions were examined using cell viability assays, real time qPCR analysis of total RNA, as well as immunofluorescence microscopy. RESULTS: Phenotypic conversion of MSCs into ECM producing fibroblastic cells proceeds spontaneously in the presence of human platelet lysate. Administration of FGF2 and/or GDF5 enhances production of mRNAs for several ECM proteins including Collagen types I and III, as well as Tenomodulin (e.g., COL1A1, TNMD), but not Tenascin-C (TNC). Differences in the in situ deposition of ECM proteins Collagen type III and Tenascin-C were validated by immunofluorescence microscopy. SUMMARY: Treatment of MSCs with FGF2 and GDF5 was not synergistic and occasionally antagonistic for ECM production. Our results suggest that GDF5 alone enhances the conversion of MSCs to fibroblastic cells possessing a phenotype consistent with that of connective-tissue fibroblasts.

Intra-articular ligamentous injuries are typically unrepairable and have limited outcomes after graft reconstruction. A combination of porous polycaprolactone fumarate (PCLF) scaffolds with polyethylene terephthalate (PET) sutures was developed with the goal of regenerating intra-articular ligaments. Scaffolds were fabricated by injecting PCLF over three-dimensional-printed molds containing two strands of PET suture down its central pore followed by cross-linking. Scaffolds were seeded with human mesenchymal stem cells (MSCs) from adipose tissue. To demonstrate cell attachment and proliferation in culture, we performed live/dead staining and cell proliferation assays. These experiments showed that MSCs remain viable and continue to proliferate on the scaffolds in culture for at least 2 weeks. Bare scaffolds were then used to reconstruct the rabbit anterior-cruciate ligament (ACL), while control rabbits underwent semitendinosus autograft reconstruction. The specimens underwent micro-computed tomography (CT) imaging, histological examination, and biomechanical testing at 8 weeks. The ultimate pull-out strength of the PCLF-PET scaffolds and tendon autografts was initially 72 ± 30 N and to 45 ± 10 N, respectively (p 0.06). On inspection after 8 weeks in vivo, the intra-articular portion of the PCLF-PET scaffolds was fragmented while the tendon autografts remained intact. Cross-sectional areas of bone tunnels in the PCLF-PET scaffolds (11.3 ± 1 mm

Background Management of shoulder arthritis associated with deltoid paralysis can be very challenging. The purpose of this study was to report the outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer to reconstruct the anterior deltoid in patients with symptomatic shoulder arthritis and a paralyzed deltoid. Methods This study included 31 patients with an average age of 51 years (range, 27-73 years). All patients had chronic deltoid paralysis with significant loss of function due to progressive arthritis associated with rotator cuff deficiency. All patients underwent reverse shoulder arthroplasty with pedicled pectoralis muscle transfer. Additional transfers were performed in patients with no preoperative external rotation: 5 underwent latissimus transfer, and 3 underwent direct lower trapezius transfer to the infraspinatus. Results At an average follow-up of 37 months, 29 patients had significant improvements in pain; the shoulder subjective value; the Disabilities of the Arm, Shoulder and Hand score; and shoulder range of motion, mainly flexion of 83° and external rotation of 15°. Two patients sustained postoperative acromial fractures and had persistent pain after surgery with minimal improvement in shoulder flexion and external rotation. One of them had a failed attempt at open reduction–internal fixation of the acromion. Conclusion Reverse shoulder arthroplasty with pedicled pectoralis transfer is a promising procedure that may lead to improved pain and function in patients with shoulder arthritis associated with deltoid paralysis.

Instability after shoulder arthroplasty remains a complication with limited salvage options. Reoperation for instability with anatomic designs has led to high rates of persistent instability, therefore we aimed to evaluate the use of RSA for treatment of prosthetic instability. (1) After revision shoulder arthroplasty to a reverse prosthesis (RSA), what is the survivorship free from dislocations at 2 and 5 years? (2) What factors are associated with dislocations? (3) What is the survivorship free from revision after revision to RSA? (4) From preoperation to postrevision to RSA, what are the clinical outcomes—the proportion of patients with moderate to severe pain, shoulder elevation and external rotation ROM, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores? All shoulder arthroplasties revised for prosthetic instability using RSA components between January 2004 and July 2014 were retrospectively studied. During the period in question, we performed 82 revisions for instability of an anatomic total shoulder arthroplasty (TSA) (n = 62), hemiarthroplasty (n = 13), or reverse TSA (n = 7). We typically used a reverse TSA to treat this problem, but we identified 12 treated in other ways, including revision of a TSA to hemiarthroplasty (n = 3), revision of a reverse TSA to hemiarthroplasty (n = 2), revision of hemiarthroplasty to a hemiarthroplasty (n = 1), and revision of an anatomic TSA to another anatomic TSA (n = 6). This left 70 patients for evaluation; of those, 65 (93%) were available for analysis at a mean of 3 years (range, 2–10 years). A total of seven patients died. Eight of the 65 shoulders were not evaluated during the last 5 years, including three in patients who died earlier. The mean age of the patients at the time of revision RSA was 65 years (range, 40–89 years). Data were obtained from a longitudinally maintained institutional joint registry. Instability was defined as severe subluxation confirmed on clinical and radiographic examinations. We evaluated pain and ROM, and Kaplan-Meier curves were used to estimate survivorship. The survivorship free from dislocation at 2 and 5 years was 87% (95% CI, 80%–94%) and 79% (95% CI, 67%–91%) respectively, with 10 of 65 (15%) patients having an episode of dislocation after revision surgery. Persistent instability was more common in those with a BMI greater than 35 kg/m2 (hazard ratio [HR], 5; 95% CI, 2–16; p = 0.008) and prior hemiarthroplasty (HR, 5; 95% CI, 2–16; p = 0.005), whereas patients who had undergone a previous TSA were less likely to have persistent instability (HR, 0.08; 95% CI, 0.0–0.30; p < 0.001) The survival free from rerevision for any indication at 2 and 5 years was 85% (95% CI, 76%–94%) and 78% (95% CI, 66%–90%) respectively; with the numbers available, we were not able to find associated factors. Fewer patients had moderate or severe pain after revision to RSA (preoperative: 48 of 65 [74%]; postoperative: nine of 65 [14%]; p < 0.001). After surgery, patients showed improvement in shoulder elevation (preoperative: 42° [± 30°], postoperative: 112° [42°]; mean difference, 70° [95% CI, − 83o to 57°]; p < 0.001) and external rotation (preoperative: 20° [± 22°], postoperative: 42° [± 23°]; mean difference, 22° [95% CI, − 30° to − 14°]; p < 0.001). American Shoulder and Elbow Surgeons scores improved (preoperative: 21 [± 10], postoperative: 68 [± 14], mean difference, 46 [95% CI, − 58 to − 35]; p < 0.001); where a higher score is better. Simple Shoulder Test scores also improved (preoperative: 2/12 [± 2], postoperative: 7/12 [± 3]; mean difference, 5 [95% CI, − 7 to − 2.17]; p < 0.001); where a higher score is better. Revision RSA for prosthetic instability after shoulder arthroplasty is associated with reasonable implant survival and few complications. Approximately one in seven patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RSA. Level IV, therapeutic study.

The purpose was to determine if smartphone photography is a reliable tool in measuring wrist movement. Smartphones were used to take digital photos of both wrists in 32 normal participants (64 wrists) at extremes of wrist motion. The smartphone measurements were compared with clinical goniometry measurements. There was a very high correlation between the clinical goniometry and smartphone measurements, as the concordance coefficients were high for radial deviation, ulnar deviation, wrist extension and wrist flexion. The Pearson coefficients also demonstrated the high precision of the smartphone measurements. The Bland–Altman plots demonstrated 29–31 of 32 smartphone measurements were within the 95% confidence interval of the clinical measurements for all positions of the wrists. There was high reliability between the photography taken by the volunteer and researcher, as well as high inter-observer reliability. Smartphone digital photography is a reliable and accurate tool for measuring wrist range of motion. Level of evidence: II

Although anatomic and reverse total shoulder arthroplasty (TSA) are generally very successful procedures with predictable pain relief, a small percentage of patients experience refractory pain postoperatively. Common etiologies of pain following such surgery are infection and joint instability in the early postoperative period, as well as implant loosening beyond 2 years postoperatively. However, once these causes of pain are ruled out, less common etiologies should be considered. These less common causes of postoperative pain include psychological factors (i.e., depression and anxiety), physiologic (i.e., narcotic dependence and neurologic), mechanical (i.e., symptomatic hardware and acromioclavicular arthritis), or secondary gain (i.e., workman's compensation and insurance issues).

The majority of proximal humerus fractures are minimally displaced and good outcomes can be achieved with nonoperative treatment strategies. However, controversy exists regarding the best management of highly comminuted and displaced proximal humerus fractures that occur in elderly patients with poor bone quality. Although surgical options including open reduction and internal fixation or hemiarthroplasty can restore excellent function, the rate of catastrophic failure remains high measuring between 20% and 40%. Reverse total shoulder arthroplasty has recently been introduced as a means for treatment of these fractures with intermediate results demonstrating improved range of motion, functional outcomes, and lower rates of revision.

Background The purpose of this study was to determine the complications and results of cement-within cement-humeral fixation in revision reverse shoulder arthroplasty. Methods In 38 shoulders, a cemented humeral component was revised to a cemented reverse humeral component using a cement-within-cement technique. The mean follow-up time was 3.7 (2.0-7.0) years. Clinical, radiologic, and hard outcomes were assessed using the Kaplan-Meier survival method, Fisher exact test, and Student t -test. Results The average operative time for the cement-within-cement technique was 153 minutes. There were 7 (18%) nondisplaced intraoperative fractures involving the greater tuberosity that occurred on implant removal; all healed at last follow-up. A second revision surgery was performed in 3 (8%) patients who underwent cement-in-cement humeral component revision for glenoid loosening (n = 1), periprosthetic instability associated with glenoid loosening (n = 1), and periprosthetic humerus fracture (n = 1). The overall implant revision-free survival at 2 and 5 years was 95% and 91%, respectively. Patients experienced significant pain relief, improvements in their shoulder range of motion, and high satisfaction. There was 1 "at-risk" humeral component (grade 4 or higher humeral lucency, moderate subsidence) that did not undergo revision surgery. There were 2 other humeral components with grade 3 humeral lucency, no subsidence. Conclusions Cement-within-cement fixation of the humeral component in revision reverse shoulder arthroplasty is associated with a reasonable operative time, good medium-term survival rates, and good pain relief and functional outcomes with low complications. This technique is an important consideration to preserve humeral bone stock and potentially humeral component and implant stability.

Background The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component. Methods During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2). Results At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P

Current treatment options for cartilage injuries are limited. The goals of this study are to create a biodegradable polymer scaffold with the capabilities of sustaining chondrocyte growth and proliferation, enable cell-to-cell communication and tissue regeneration through large pores, and assess the biological augmentation of the scaffold capabilities using platelet lysate (PL). We synthesized biodegradable polycaprolactone fumarate (PCLF) scaffolds to allow cell-cell communication through large interconnected pores. Molds were printed using a three-dimensional printer and scaffolds synthesized through UV crosslinking. Culture medium included alpha modified Eagle's media with either 10% fetal bovine serum (FBS) or 5% PL, a mixture of platelet release products, after being seeded onto scaffolds through a dynamic bioreactor. Assays included cellular proliferation (MTS), toxicity and viability (live/dead immunostaining), differentiation (glycosaminoglycan [GAG], alkaline phosphatase [ALP], and total collagen), and immunostaining for chondrogenic markers collagen II and Sox 9 (with collagen I as a negative control). The large interconnected pores (500 and 750 μm) enable cell-to-cell communication and cellular infiltration into the scaffolds, as the cells remained viable and proliferated for 2 weeks. Chondrocytes cultured in PL showed increased rates of proliferation when compared with FBS. The chondrogenic markers GAG and total collagen contents increased over 2 weeks at each time point, whereas the osteogenic marker ALP did not significantly change. Immunostaining at 2 and 4 weeks for the expression of chondrogenic markers Collagen II and Sox 9 was increased when compared with control human fibroblasts. These results show that the PCLF polymer scaffold enables chondrocytes to attach, proliferate, and retain their chondrogenic phenotypes, demonstrating potential in chondrocyte engineering and cartilage regeneration.

Purpose To examine the long-term outcome of patients aged less than 45 years who underwent either proximal row carpectomy (PRC) or 4-corner arthrodesis (4CA) for wrist arthritis. Methods We reviewed a retrospective cohort of 89 patients aged less than 45 years who underwent either 4CA (n = 51) or PRC (n = 38) for wrist arthritis. Mean follow-up was 11 years in the 4CA group and 18 years in the PRC group. Results Overall, there were no differences between groups in the need for revision surgery. Complications included 6 nonunions in the 4CA group (12%), 1 infection in each group, and 11 patients who experienced radiocarpal impingement (8 4CA and 3 PRC). There was no difference in the number of patients reporting moderate or severe pain between the PRC and 4CA groups. Mean flexion-extension arc was 54° after 4CA, compared with 73° after PRC. Patients who underwent 4CA had slightly improved grip strength (65% of the opposite side) compared with those who had PRC (54%). Mean postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 32 versus 19 (PRC vs 4CA) and patient-rated wrist evaluation scores were 27 versus 28 (PRC vs 4CA). Comparing radiographic arthritis, the 10-year outcome, free of moderate/severe arthritis for the PRC and 4CA groups, was 70% and 71%, respectively. Conclusions Both PRC and 4CA represent a good surgical option for young patients with wrist arthritis, with similar complication rates, postoperative pain levels, wrist function, and long-term outcomes free of arthrodesis. Proximal row carpectomy has improved motion and fewer complications. Type of study/level of evidence Therapeutic IV.

Background The purpose of the present study was to determine the cost of two-stage reimplantation for the treatment of deep infection after total elbow arthroplasty (TEA) and compare this with primary and aseptic revision TEA. Methods Three hundred and seventy-one primary TEA and 286 revision TEAs (including 47 elbows requiring two-stage reimplantation) were performed. Total direct medical costs during each hospitalization were obtained from our institutional research database and compared for three groups: primary TEA, revision for nonseptic reasons and two-stage reimplantation for deep infection. Results The mean cost of an uncomplicated primary TEA and aseptic revision TEA was $18,464 and $18,796, respectively. The mean overall cost associated with two-stage reimplantation increased to $34,286. Two-stage reimplantation increased both Part A (hospital costs) and Part B (professional costs). The mean Part A cost for septic revision TEA was $29,102 versus $15,844 for primary TEA. The mean Part B cost for septic revision TEA was $5,184 versus $2,621 for primary TEA. Conclusions Two-stage reimplantation for treatment of an infected TEA costs 186% the hospital cost of a primary uncomplicated or aseptic revision TEA. The overall cost to society is even greater if we take into account the cost of antibiotic therapy in between stages and lost days from work.

Background: Giant cell tumor (GCT) of bone is a benign, though locally aggressive tumor, classically described as an eccentric lytic lesion, often with cortical expansion and destruction. It typically involves the metaphysis or epiphysis of long bones in skeletally mature patients, with a slight female predominance. The incidence in the small bones of the hand has been reported to be 2% to 5%. Methods: Treatment options have evolved in recent years, and currently include intralesional curettage with or without adjuvant therapy, wide resection, and occasionally amputation. Results: In this report, we present a long-term follow-up (10 years) of a patient with GCT involving a metacarpal, who was initially reconstructed with a metacarpal head allograft, which was eventually revised to a metacarpophalangeal (MCP) total joint arthroplasty. Conclusions: To our knowledge, this is the only report of pyrocarbon being used for tumor reconstruction and the only report of late MCP allograft salvage.

Osteosarcoma is a bone tumor that mainly affects children and adolescents. Although its pathogenesis is still not fully understood, activation of Wnt signaling has been implicated in the development and metastasis of osteosarcoma. In this report, we have investigated the effect of the anti-tumor compound, 2-methoxyestradiol (2-ME) on Wnt antagonist frizzled-related protein b (Frzb), also known as secreted frizzled-related protein (sFRP)3 in human osteosarcoma (MG63) cells. Our results show that 2-ME treatment induces Frzb gene promoter activity, and increases Frzb mRNA and protein levels in osteosarcoma cells. In addition, 2-ME treatment regulates downstream Wnt signaling, increasing the cytoplasmic levels of β-catenin, and blocking β-catenin-mediated Wnt activation in osteosarcoma cells. 2-ME-mediated induction of Frzb protein expression is specific to osteosarcoma cells, as it does not affect Frzb expression in normal primary human osteoblasts. Furthermore, 2-ME-induced apoptosis and autophagy are blocked in osteosarcoma cells transfected with Frzb siRNAs. Taken together, these studies demonstrate that Frzb protein plays an important role in 2-ME-mediated anti-tumor mechanisms in osteosarcoma cells. J. Cell. Biochem. 118: 1497-1504, 2017. © 2016 Wiley Periodicals, Inc.

Reverse total shoulder arthroplasty (RTSA) has classically been reserved for patients older than 65 years with rotator cuff arthropathy, pseudoparalysis, and severe pain. This investigation assessed outcomes in a consecutive series of patients aged 65 and younger undergoing primary RTSA.There were 63 patients (67 shoulders; 40 women, 27 men) with a mean age of 60 years (range, 50-65 years). Indications were cuff tear arthropathy (CTA) in 51, severe glenohumeral arthritis in 15, and osteonecrosis in 1. The primary end point was revision-free implant survival. Pain scale, motion, strength, and radiographic outcomes were also studied.At a mean follow-up of 3 years (range, 2-8 years), the 2-year and 5-year revision-free survival was 99% and 91%, and reoperation-free survival was 97% and 90%, respectively. Complications occurred in 9%. Smoking increased the risk for revision, reoperation, and complications (P .03). Patients experienced improvements in pain (P .0001), active abduction (57.5° vs. 132.4°, P .0001), and active external rotation (20.1° vs. 39.4°, P .001). At the most recent follow-up, 90% patients were satisfied with their result, and 85% felt they were better or much better than before surgery. There was an 18% incidence notching, 3% incidence of dislocation, and no loosening.At both 2 and 5 years, RTSA is a reliable operation in patients aged younger than 65 years. Patients gain significant improvements in pain level, range of motion, and strength, without a large number of early failures. Long-term follow-up is needed to understand late component mechanical problems and loosening.

Soft tissue wounds overlying the dorsum of the foot and ankle are difficult to treat, and historically have been treated with free tissue transfer. Advances in surgical technique have expanded the use of pedicle perforator flaps to avoid free tissue transfer in certain situations. The authors describe a technique for using an extensor digitorum brevis flap to provide soft tissue coverage for wounds of the ankle and foot. In the senior authors' experience, the use of this flap has achieved wound coverage in 100% of patients with smaller wounds (≤45 cm) of the ankle.

The purpose of this study is to analyze the outcomes of open and arthroscopic capsular release following total shoulder arthroplasty. Over 15 years, 19 patients experienced persistent shoulder stiffness after anatomic total shoulder arthroplasty refractory to nonoperative treatment, requiring either open (n = 5) or arthroscopic (n = 14) capsular release. There were seven (39%) patients who had a prior diagnosis of stiffness before the primary arthroplasty. At a follow-up of 2.3 years (1–5.5), there were changes in range of motion, including forward flexion (77°–117°), abduction (49°–98°), external rotation (9°–19°), internal rotation at 0° (Sacrum to L1), and pain (4.1–2.3) scores (p

Background There is a paucity of information on latissimus dorsi transfer (LDT) for subscapularis insufficiency. The purpose of this study is to report the outcome of LDT to reconstruct an irreparable subscapularis tear. Methods Excluding patients with prior failed Latarjet procedures, we examined 56 consecutive patients who underwent open (n = 14) or arthroscopic (n = 42) LDT. The average age was 53 years (range, 23-79), and 46 patients had a prior surgery. Outcome measures included visual analog scale score for pain, range of motion (ROM), subjective shoulder value (SSV), and Constant shoulder score (CSS). Results At a mean 13-month follow-up (7-51 months), patients had significant improvements in their pain, ROM, SSV, and CSS when compared to preoperatively. At final follow-up, 26% of patients continued to have proximal migration, and 11% of patients had anterior subluxation. The patients with frank anterior escape had a higher likelihood of having proximal migration and anterior subluxation, but this was not statistically significant. Stages of arthritis did not progress. Revision surgeries included 2 patients who revised to a reverse shoulder arthroplasty for rupture of the tendon transfer. Furthermore, 3 patients had LDT ruptures but did not elect to undergo further surgery. Conclusions LDT for irreparable subscapularis tears has the potential to lead to significant clinical improvements. Most patients improve in many of the signs of subscapularis insufficiency, including anterior and/or proximal subluxation, clinical examination maneuvers, and shoulder function. Overall, this transfer represents a reasonable option for this difficult pathology.

Anterior glenohumeral instability is common, with 21.9 first-time dislocations per 100,000 individuals per year. Recurrent instability is more likely to occur in patients who are younger, of male sex, and have bone defects or ligament laxity. The open Latarjet procedure is effective for the treatment of recurrent anterior glenohumeral instability and is preferred over arthroscopic Bankart repair in the presence of glenoid bone loss. The Latarjet procedure involves transferring the coracoid to the anterior aspect of the glenoid in the following steps. Step 1: Preoperative planning includes an assessment of glenoid deformation and the integrity of the rotator cuff. The degree of bone loss is measured with use of the circle-line method. Step 2: The patient is in the beach-chair position with the arm in a pneumatic arm holder. A parallel drill guide system with 3.75-mm cannulated screws is utilized. Step 3: A 5-to-6-cm incision is made along the anterior axillary line. The deltopectoral interval is established, and the cephalic vein is mobilized laterally. The coracoacromial ligament is transected 15 mm lateral to the coracoid to allow later repair to the anterior capsule. The pectoralis minor is released subperiosteally off the medial coracoid. A 90° oscillating saw is used to transect the coracoid medially to laterally. The coracohumeral ligament is released. Step 4: Two 4.0-mm drill-holes are made 1 cm apart through the coracoid. The undersurface is decorticated. Step 5: The subscapularis is split at the junction of the upper two-thirds and lower one-third. A longitudinal capsulotomy is performed parallel to the glenoid. Step 6: Soft tissue, including the capsule and labrum, is removed from the anterior aspect of the glenoid. The bone is decorticated with an osteotome and a rasp. Step 7: The coracoid is positioned flush or 1 mm recessed relative to the glenoid. Two 1.6-mm guidewires are placed with use of a parallel drill guide followed by a cannulated reamer and two 3.75-mm cannulated screws. Step 8: The coracoacromial ligament is repaired to the capsule. Step 9: The subscapularis split is repaired laterally. The deltopectoral interval and skin are closed in a standard fashion. A standardized rehabilitation protocol is employed postoperatively. The Latarjet procedure results in significantly lower rates of recurrent glenohumeral instability and revision compared with the arthroscopic Bankart procedure (3% and 1% compared with 28.4% and 21%, respectively); however, complication rates as high as 30% have been reported, as well as a risk for nerve injury. The videos included in this article highlight the critical steps required to optimize outcomes and minimize complications when performing the Latarjet procedure.

Introduction This investigation compares the outcomes of proximal interphalangeal (PIP) arthroplasty in patients older than and younger than 60 years. Methods Overall, 299 consecutive, primary PIP arthroplasties were performed over a 14-year period, including 126 arthroplasties performed in patients younger than 60 years. In younger patients group, a higher rate of posttraumatic and inflammatory arthritis was observed. Results In patients younger than 60 years, 32 (25%) revision surgeries occurred. Risk of revision surgery was associated with younger age. The 10-year implant survival rate was 72% for the patients younger than 60 years versus 86% for those older than 60 years. Silicone implants decreased the risk of revision surgery, although it was increased in posttraumatic arthritis. The most common complication in young patients was dislocation (n = 21). At a mean follow-up of 6.4 years, pain levels had significantly improved in patients younger than 60 years, and PIP range of motion and pinch strength were maintained. However, older patients had improved PIP motion compared with younger patients. Conclusions Younger age leads higher revision rates after PIP arthroplasty, particularly in the posttraumatic setting. Level of evidence Therapeutic, level III.

Posterior shoulder instability remains a poorly understood pathologic entity. Our current treatment algorithm of simple posterior shoulder instability is fairly straightforward, with most patients receiving arthroscopic capsulorrhaphy with labral repair. However, in those with a failed arthroscopic intervention and/or with bony pathology, the optimal treatment is much less clear. As we move forward to evaluate how to optimally treat these patients, it will be critical to better understand the bony pathologies, including those with true posterior glenoid bone loss versus glenoid retroversion. Using novel methods to identify, measure, and quantify the different glenoid morphologies will be the foundation for improving the treatment of these complex and poorly understood pathologies.

Recent media reports have described knife injuries sustained while preparing avocados; however, this rise has not been reported in the literature. The purpose of this study is to describe, quantify, and trend emergency department (ED) encounters associated with avocado-related knife injuries.The National Electronic Injury Surveillance System (NEISS) was queried for avocado-related knife injuries from 1998 to 2017. Patient demographic and injury data was collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an ED encounter for an avocado-related knife injury.There were an estimated 50,413 (95% Confidence Interval: 46,333-54,492) avocado-related knife injuries from 1998 to 2017. The incidence of avocado-related knife injuries increased over this time period (1998-2002 = 3143; 2013-2017 = 27,059). This increase correlated closely with a rise in avocado consumption in the U.S. (Pearson's Correlation: 0.934, p 0.001) Women comprised 80.1% of injuries. The most common demographic injured were 23 to 39-year old females (32.7%), while the least common was males under the age of 17 (0.9%). Most ED presentations occurred on Saturdays (15.9%) or Sundays (19.9%) and the majority occurred during the months of April through July (45.6%). Injuries were much more common on the left (and likely non-dominant) hand.Avocado-related knife injuries are a preventable cause of hand injury. The incidence has risen significantly in recent years, possibly due to an increased consumption of avocados in the United States. Education on safe avocado preparation techniques and public safety initiatives, such as warning labels, could help prevent serious injuries in the future.

Tendinopathy and tendinitis are some of the most frequently encountered disorders in hand and upper extremity surgery. Patients often present with progressively increasing pain over a subacute or chronic period. In most cases it is a clinical diagnosis, with confirmation via advanced imaging. First-line treatment consists of conservative measures such as activity modification, splints, and injections. After a 3- to 6-month trial of nonoperative treatment, surgery usually involves decompression of the involved tendons and debridement of any inflammatory tissue. Patient and anatomic factors can affect the outcomes of both nonoperative and operative treatments.

Introduction There has been a spike in recent news regarding motorized scooter injuries due to the expansion of scooter sharing companies. Given the paucity of literature on this topic, the purpose of our study was to describe and quantify emergency department encounters associated with motorized scooter related injuries. Methods The National Electronic Injury Surveillance System (NEISS) was queried for motorized scooter related injuries from 2013 to 2017. Patient demographics, diagnosis, injury location, narrative description of incident, and disposition data were collected from emergency department encounters. Results There were an estimated 32,400 motorized scooter injuries from 2013 to 2017. The estimated incidence did not change significantly over time with 1.9 cases per 100,000 in 2013 and 2.6 cases per 100,000 in 2017. A 77.0% increase in scooter injuries was noted for millennials from 2016 to 2017. Head injuries were the most common body area injured (27.6%). Fractures or dislocations (25.9%) were the most common diagnosis. The most common site of fracture was the wrist and lower arm (35.4%). There were no deaths. Major orthopaedic injury and concussion were the strongest independent predictors of hospital admission. Conclusions Head injuries were the most commonly injured body part, while fractures or dislocations were the most common diagnosis. These results highlight the importance of using protective equipment while riding motorized scooters, and lay a foundation for future policies requiring helmet use.

Background: The purpose of this study was to review the outcomes associated with different surgical treatments in the management of suppurative flexor tenosynovitis (SFT). Methods: Patients treated by open drainage (OD) through a single incision and closed catheter irrigation (CCI) of the tendon sheath were evaluated from 2003 to 2009 at a single institution. Variables examined included culture results, time to surgery, duration of hospitalization and antibiotic therapy, pain, reoperation, and functional outcomes were recorded. Statistical analyses used included parametric and nonparametric t tests. Results: Twenty-four patients were treated for SFT with a mean follow-up of 3 ± 2 years. There were 13 (100%) males in the OD group compared to 8 (72%) males within the CCI group. Ninety-two percent of patients who underwent OD and 100% who underwent CCI reported none or mild pain. There were no differences between the 2 groups with regard to functional outcome scores. Factors leading to worse functional outcomes included prolonged time to receiving antibiotics and Staphylococcus aureus infection. Smokers required prolonged antibiotic treatment compared to nonsmokers. Accounting for planned returns to the operating room, there was no difference in reoperation rates between the OD or CCI groups. Conclusions: Surgical treatment of SFT with either OD or CCI resulted in similar outcomes for pain, function, and need for reoperation. Factors that lead to poor outcomes include S aureus culture, prolonged time to antibiotics, and smoking.

Tendon transfer options to reconstruct a massive irreparable posterior-superior rotator cuff tear include latissimus dorsi, teres major, or lower trapezius transfer. We previously described the lower trapezius transfer using a 2-incision approach, which includes a medial incision to harvest the lower trapezius and lateral transacromial incision to expose the rotator cuff and then perform the transfer through a deep tunnel connecting these 2 sites. In this report, we describe an arthroscopic-assisted technique of lower trapezius transfer augmented with an Achilles tendon allograft to reconstruct an irreparable posterior-superior rotator cuff tear.

Background Morbid obesity has been associated with increased complications after primary total knee arthroplasty (TKA), but previous studies have failed to take factors such as body composition and fat distribution into consideration. The aims of this study were to (1) assess the interobservable and intraobservable reliabilities of measuring anterior knee subcutaneous fat thickness on lateral knee radiographs and (2) determine if these measurements associate with early complications in patients with morbid obesity. Methods Using a retrospective case-control analysis, we reviewed 1689 primary TKAs performed in morbidly obese patients at our institution from 1995 to 2012. All patients (n = 58) who required reoperation for wound complication or infection within 90 days were compared to a matched cohort of morbidly obese patients who did not require early reoperation. Distances from patella skin (prepatellar thickness) and tibial tubercle skin (pretubercular thickness) were measured on routine lateral knee radiographs and associated with outcomes. Results Intraobserver and interobserver reliabilities were excellent for both measurements. Knees in the reoperation group had significantly greater prepatellar ( P = .0001) and pretubercular ( P = .0006) soft tissue thickness. Prepatellar thickness ≥15 mm and pretubercular thickness ≥25 mm increased the risk of early reoperation by 2.0× ( P = .0003) and 1.6× ( P = .023), respectively, and were more predictive measurements than body mass index. Conclusion Anterior knee subcutaneous fat thickness can be reproducibly measured on lateral knee radiographs and is associated with a significantly increased risk of early reoperation for wound complications and infection after primary TKA in morbidly obese patients.

Purpose Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results. Methods Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included “clinically useful ER” (motion ≥ −35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation. Results EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: −60° to 90°) and MRC grade 2.2 (2–4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P

Purpose To evaluate the outcome of contralateral lower trapezius origin transfer (CLTOT) to restore shoulder external rotation in patients with shoulder paralysis after brachial plexus injury (BPI). Methods We evaluated 12 patients with a history of BPI with persistent shoulder paralysis. All patients had compromised ipsilateral lower trapezius muscle function. All patients underwent CLTOT prolonged with lumbar fascia to the affected infraspinatus tendon either isolated (7 patients) or as part of multiple tendon transfer (5 patients). Standardized patient outcomes measures were obtained. Results At 23 months' follow-up, 10 patients had improved shoulder external rotation from no motion preoperatively to an average external rotation 110° from the abdomen. Five patients had marked improvement of pain, including 2 with isolated CLTOT and 3 with additional tendon transfers. Two patients experienced no change in pain. There were noted improvements in the Constant shoulder scores, simple shoulder value, and Disabilities of the Arm, Shoulder, and Hand scores. One patient sustained a fall resulting in stretch injury to the transfer, underwent successful revision surgery, and regained 100° active shoulder external rotation away from the abdomen more than a year after revision surgery. Another patient's transfer failed during rehabilitation but the patient elected not to pursue treatment. No patients had changes in contralateral shoulder motion or strength or any pain from the contralateral shoulder. Conclusions This study demonstrated that CLTOT to the infraspinatus tendon was effective in improving shoulder external rotation in patients with BPI. Type of study/level of evidence Therapeutic IV.