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The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study ( p = .002) and a strong, positive correlation ( p = .007) were evident. Annual TEA ( p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Aim: To examine whether opioid dependence or abuse has an effect on opioid utilization after anatomic or reverse total shoulder arthroplasty (TSA)., Methods: All anatomic TSA (ICD-9 81.80) and reverse shoulder arthroplasty (RSA) (ICD-9 81.88) procedures from 2007 to 2015 were queried from within the Humana claims database utilizing the PearlDiver supercomputer (Colorado Springs, CO). Study groups were formed based on the presence or absence of a previous history of opioid dependence (ICD-9 304.00 and 304.03) or abuse (ICD-9 305.50 and 305.53). Opioid utilization among the groups was tracked monthly up to 1 year post-operatively utilizing National Drug Codes. A secondary analysis was performed to determine risk factors for pre-operative opioid dependence or abuse., Results: Two percent of TSA (157 out of 7838) and 3% of RSA (206 out of 6920) patients had a history of opioid dependence or abuse. For both TSA and RSA, opioid utilization was significantly higher in opioid dependent patients at all post-operative intervals ( P < 0.01) although the incidence of opioid use among groups was similar within the first post-operative month. After TSA, opioid dependent patients were over twice as likely to fill opioid prescriptions during the post-operative months 1-12. Following RSA, opioid dependent patients were over 3 times as likely to utilize opioids from months 3-12. Age less than 65 years, history of mood disorder, and history of chronic pain were significant risk factors for pre-operative opioid dependence/abuse in patients who underwent TSA or RSA., Conclusion: Following shoulder arthroplasty, opioid use between opioid-dependent and non-dependent patients is similar within the first post-operative month but is greater among opioid-dependent patients from months 2-12., Competing Interests: Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.

Background: Morbid obesity has been linked with serious associated injuries following dislocations of the knee. While similar devastating injuries have been observed following elbow dislocations in the obese, no study to date has characterized the financial impact of elbow dislocations in the morbidly obese population., Purpose: The purpose of this study is to determine the impact of morbid obesity on 1-year costs related to elbow dislocation., Methods: A retrospective query of the Medicare Standard Analytic Files database was performed for patients sustaining elbow dislocation from 2005 to 2014. 1-year reimbursement costs from the initial open or closed reduction procedures were compared for morbidly obese (BMI ≥ 40 kg/m 2 ) patients versus those without morbid obesity (BMI < 40 kg/m 2 ). Cohorts were matched based on age and gender. Total reimbursement costs associated with a diagnosis of elbow dislocation and/or reduction were analyzed., Results: We identified 182 morbidly obese patients and 422 patients without morbid obesity who underwent open or closed reduction for elbow dislocation. 102 patients with 1-year cost data remained in each cohort after matching. Mean 1-year reimbursement costs related to elbow dislocation were significantly greater in morbidly obese patients ($6227.43 vs $4225.71, p = 0.006)., Conclusion: 1-year costs related to elbow dislocation are significantly higher in morbidly obese patients. The increased costs likely reflect the complexity of managing dislocations in the obese population. Difficulties maintaining closed reduction, longer and more challenging surgeries with a higher likelihood on intra- and post-operative complications, and a higher risk of peri-operative medical complications may all contribute to these increased costs.

Introduction: This study determines the incidence of opioid use before shoulder arthroplasty and analyzes its influence on postoperative use., Methods: A retrospective analysis of patients undergoing shoulder arthroplasty with at least 2-year follow-up was performed. Then, at pre- and postoperative appointments, the patients were asked "Do you take narcotic pain medication (codeine or stronger)?", Results: Among 490 patients included in the study, 35.5% reported preoperative opioid use. These patients had higher incidence of opioid use at 1-year follow-up (29.1% versus 4.9%; odds ratio, 8.320; P < 0.001) and at final follow-up (35.1% versus 7.3%; odds ratio, 6.877; P < 0.001). Opioid usage did not change markedly from 1 year follow-up to final follow-up (P > 0.18)., Discussion: Approximately one-third of patients used opioids preoperatively and were seven times more likely to continue opioid use postoperatively. Opioid usage did not change from 1 year follow-up to final follow-up, suggesting that patients still using opioids at their 1-year appointment were likely to continue opioid use., Level of Evidence: Level III.

Both anatomical total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are routinely performed for patients who desire to continuously work or participate in sports. This study analyzes and compares the ability of patients to work and partake in sports following shoulder arthroplasty based on responses to clinical outcome surveys. A retrospective review of the shoulder surgery repository was performed for all patients treated with TSA and RSA and who completed questions 9 and 10 on the activity patient self-evaluation portion of the American Shoulder and Elbow Surgeons (ASES) Assessment Form. Patients with a minimum of 1-year follow-up were included if a sport or work was identified. The analysis included 162 patients with TSA and 114 patients with RSA. Comparisons were made between TSA and RSA in terms of the specific ASES scores (rated 0-3) reported for ability to work and participate in sports and total ASES scores, and scores based on specific sports or line of work reported. Comparisons were also made between sports predominantly using shoulder function and those that do not. TSA patients had a 27% higher ability to participate in sports (average specific ASES score: 2.5 vs 1.9, P < .001) than RSA patients and presented significantly higher scores for swimming and golf. Compared with RSA patients, TSA patients demonstrated more ability to participate in sports requiring shoulder function without difficulty, as 63% reported maximal scores (P = .003). Total shoulder arthroplasty patients also demonstrated a 21% higher ability to work than RSA patients (average specific ASES scores: 2.6 vs 2.1, P < .001), yielding significantly higher scores for housework and gardening. Both TSA and RSA allow for participation in work and sports, with TSA patients reporting better overall ability to participate. For sports involving shoulder function, TSA patients more commonly report maximal ability to participate than RSA patients., Competing Interests: Authors' Disclosure Statement: Dr. Levy reports that he is a paid consultant of Globus Medical and DJO Orthopaedics; receives research grant funding from DJO Orthopaedics, Zimmer Biomet, Wright Medical, Rotation Medical, and OrthoSpace; and receives royalties from Innomed and DJO Orthopaedics. The other authors report no actual or potential conflict of interest in relation to this article.

Background: Latissimus dorsi transfers have been considered necessary to restore active external rotation following reverse shoulder arthroplasty (RSA). The purpose of this study was to assess the effectiveness of an RSA system that lateralizes the center of rotation in restoring active external rotation without a latissimus dorsi transfer in patients with a preoperative external rotation deficit (external rotation of <0°)., Methods: We retrospectively reviewed the records of patients who had undergone RSA with a lateralized center of rotation without a latissimus dorsi transfer. All patients had had a preoperative external rotation deficit (active external rotation of <0°), and all were followed for a minimum of 2 years. Patients were stratified into 2 groups on the basis of the preoperative diagnosis: (1) those with a combined loss of active elevation and external rotation as a result of rotator cuff tear arthropathy (CLEER group) and (2) those with a combined loss of active elevation and external rotation as a result of other posttraumatic etiologies (non-CLEER group). The mean improvement of external rotation was analyzed. Subgroup analysis was performed on the basis of the Goutallier classification, glenosphere lateralization, and total prosthetic lateralization., Results: Thirty-three patients (24 in the CLEER group and 9 in the non-CLEER group) met the inclusion criteria. The average follow-up was 43.4 months (range, 24 to 77 months). External rotation improved significantly in both the CLEER group (from -21° preoperatively to 28° postoperatively; p < 0.001) and the non-CLEER group (from -19° preoperatively to 26° postoperatively; p = 0.001). Goutallier classification, glenosphere lateralization, and total prosthetic lateralization were not correlated with the degree of improvement of external rotation in either group (p > 0.05 for all)., Conclusions: RSA with a lateralized center of rotation can effectively restore external rotation without the use of a latissimus dorsi transfer in patients with a preoperative external rotation deficit as a result of rotator cuff arthropathy or other posttraumatic etiologies., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Studies that report outcomes after staged bilateral shoulder arthroplasty (BSA) are limited. This study compared the overall improvement between the first and second operated shoulders after BSA., Methods: Preoperative and postoperative motion and patient-reported outcomes for function, pain, and general health were assessed for patients who underwent BSA with a 2-year follow-up. Ultimate outcomes and the efficacy of treatment were compared between the first and second operated shoulders., Results: Seventy-three patients met the inclusion criteria (mean follow-up, 51.4 months). There were no notable differences between the first and second operated shoulders for all preoperative and postoperative variables except for the preoperative 12-item Short-Form Physical Component Score, which was greater in the second shoulder ( P = 0.005). The efficacy of treatment was not markedly different except for the Physical Component Score ( P = 0.001) and forward elevation ( P = 0.01), which were greater after the first surgery., Discussion: Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries., Competing Interests: Dr. Levy or an immediate family member has received royalties from DJ Orthopaedics and Innomed; serves as a paid consultant to DJ Orthopaedics and Globus Medical; has received research or institutional support from Biomet, Rotation Medical, and Tornier; and serves as a board member, owner, officer, or committee member of the Journal of Orthopaedics and Traumatology and Orthopaedics Today. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Berglund, Dr. Kurowicki, Dr. Triplet, Dr. Rosas, Dr. Moor, and Dr. Horn. All work was performed at the Holy Cross Orthopedic Institute, Fort Lauderdale, FL.

Case: An 80-year-old woman sustained a fracture-dislocation of the proximal aspect of the humerus with a near-complete brachial plexopathy, which was successfully managed acutely using a reverse shoulder arthroplasty (RSA) with repair of the greater and lesser tuberosities. The palsy, which was confirmed with nerve conduction studies, recovered uneventfully along with functional improvement of the shoulder. At the most recent follow-up, there was complete resolution of the plexopathy, with excellent, pain-free range of motion., Conclusion: Acute RSA with tuberosity repair may be a reasonable treatment modality in the setting of an acute brachial plexus palsy following a comminuted fracture-dislocation of the proximal aspect of the humerus in an elderly patient.

Background: Revision of unstable reverse shoulder arthroplasty (RSA) remains a significant challenge. The purpose of this study was to determine the reliability of a new treatment-guiding classification for instability after RSA, to describe the clinical outcomes of patients stabilized operatively, and to identify those with higher risk of recurrence., Methods: All patients undergoing revision for instability after RSA were identified at our institution. Demographic, clinical, radiographic, and intraoperative data were collected. A classification was developed using all identified causes of instability after RSA and allocating them to 1 of 3 defined treatment-guiding categories. Eight surgeons reviewed all data and applied the classification scheme to each case. Interobserver and intraobserver reliability was used to evaluate the classification scheme. Preoperative clinical outcomes were compared with final follow-up in stabilized shoulders., Results: Forty-three revision cases in 34 patients met the inclusion for study. Five patients remained unstable after revision. Persistent instability most commonly occurred in persistent deltoid dysfunction and postoperative acromial fractures but also in 1 case of soft tissue impingement. Twenty-one patients remained stable at minimum 2 years of follow-up and had significant improvement of clinical outcome scores and range of motion. Reliability of the classification scheme showed substantial and almost perfect interobserver and intraobserver agreement among all the participants (κ = 0.699 and κ = 0.851, respectively)., Discussion: Instability after RSA can be successfully treated with revision surgery using the reliable treatment-guiding classification scheme presented herein. However, more understanding is needed for patients with greater risk of recurrent instability after revision surgery., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Case: A 70-year-old woman presented with severe but minimally painful right glenohumeral osteoarthritis (OA), with progressive weakness and numbness radiating to the right hand. Imaging revealed a large fluid collection extending from the joint to the subcoracoid space, with a mass effect on the brachial plexus. A total shoulder arthroplasty (TSA) and decompression of a ganglion cyst were performed. Follow-up with serial electromyography demonstrated resolution of the brachial plexopathy and restoration of function., Conclusion: Ganglion cysts may arise secondary to severe glenohumeral OA and may compress the surrounding structures, producing a progressive plexopathy. Treatment of the underlying pathology with a TSA may be effective.

Background: Treatment of hyperglycemia in women with gestational diabetes mellitus (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2 to 4 weeks with limited opportunity for intervention between these visits., Objective: We conducted a randomized controlled trial to determine whether the use of a mobile phone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance., Methods: Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a mobile phone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics, and length of time in the study., Results: A total of 203 women were randomized. Blood glucose data were available for 98 intervention and 85 control women. There was no significant difference in rate of change of blood glucose (-0.16 mmol/L in the intervention and -0.14 mmol/L in the control group per 28 days, P=.78). Women using the intervention had higher satisfaction with care (P=.049). Preterm birth was less common in the intervention group (5/101, 5.0% vs 13/102, 12.7%; OR 0.36, 95% CI 0.12-1.01). There were fewer cesarean deliveries compared with vaginal deliveries in the intervention group (27/101, 26.7% vs 47/102, 46.1%, P=.005). Other glycemic, maternal, and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar (intervention: 54 days; control: 49 days; P=.23). However, there were significantly more blood glucose readings in the intervention group (mean 3.80 [SD 1.80] and mean 2.63 [SD 1.71] readings per day in the intervention and control groups, respectively; P<.001). There was no significant difference in direct health care costs between the two groups, with a mean cost difference of the intervention group compared to control of -£1044 (95% CI -£2186 to £99). There were no unexpected adverse outcomes., Conclusions: Remote blood glucocse monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Although glycemic control and maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-management lifestyle behaviors and dietetic adherence, and influence maternal and neonatal outcomes. Digital blood glucose monitoring may provide a scalable, practical method to address the growing burden of GDM around the world., Trial Registration: ClinicalTrials.gov NCT01916694; https://clinicaltrials.gov/ct2/show/NCT01916694 (Archived by WebCite at http://www.webcitation.org/6y3lh2BOQ)., (©Lucy Mackillop, Jane Elizabeth Hirst, Katy Jane Bartlett, Jacqueline Susan Birks, Lei Clifton, Andrew J Farmer, Oliver Gibson, Yvonne Kenworthy, Jonathan Cummings Levy, Lise Loerup, Oliver Rivero-Arias, Wai-Kit Ming, Carmelo Velardo, Lionel Tarassenko. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 20.03.2018.)

This corrects the article DOI: 10.1038/sdata.2017.179.

Background: Comorbidities have been shown to affect rotator cuff healing and postoperative outcomes. The purpose of this study was to analyze the effect of comorbidities on speed of recovery (SOR) and overall outcomes after arthroscopic rotator cuff repair (RCR)., Methods: We identified 627 patients who underwent primary arthroscopic RCR from 2006 to 2015. Measured motion and patient-reported outcome measures for pain and function were analyzed for preoperative, 3-month, 6-month, and 1-year intervals. Subgroup analysis of overall outcome and plateau in maximum improvement was performed for diabetes, smoking, obesity, hypercholesterolemia, and age., Results: Diabetic patients had worse pain (visual analog scale for pain) and functional outcome (American Shoulder and Elbow Surgeons function, Simple Shoulder Test, visual analog scale for function, and elevation) scores at 6 months and 1 year ( P  < .05), with an earlier plateau in recovery (6 months) for nearly all variables. Smoking had no impact on postoperative outcome scores; however, plateaus occurred earlier in smokers (6 months). Obese patients had worse American Shoulder and Elbow Surgeons function score and external rotation at 1 year ( P  < .05) with similar plateau points. No significant differences were observed in outcomes for patients with hypercholesterolemia; however, plateaus for Single Assessment Numeric Evaluation and motion occurred earlier (6 months). Outcome scores for patients older than 65 years were not significantly different from those for younger patients., Conclusion: After arthroscopic RCR, SOR for pain outpaced that for function and motion. Diabetic patients had worse outcomes and earlier plateau points. Earlier plateaus were seen for smokers and for motion in patients with obesity or hypercholesterolemia. Obese patients showed lower functional scores and external rotation. Age did not significantly influence SOR.

The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and compare the costs associated with the initial day and subsequent 89 days of care. This was conducted through a retrospective review of a national database examining patients who suffered proximal humerus fractures. Patients were stratified by type of surgical procedure performed, hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and open reduction and internal fixation (ORIF). RSA was the most costly procedure for the same-day and 90-day costs (p < 0.001). Mean initial day reimbursement costs were significantly different among treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), and ORIF ($6,745). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA, and ORIF (p = 0.112). The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial day costs. RSA was associated with the highest cost, followed by HA and ORIF.

To investigate the genetic basis of type 2 diabetes (T2D) to high resolution, the GoT2D and T2D-GENES consortia catalogued variation from whole-genome sequencing of 2,657 European individuals and exome sequencing of 12,940 individuals of multiple ancestries. Over 27M SNPs, indels, and structural variants were identified, including 99% of low-frequency (minor allele frequency [MAF] 0.1-5%) non-coding variants in the whole-genome sequenced individuals and 99.7% of low-frequency coding variants in the whole-exome sequenced individuals. Each variant was tested for association with T2D in the sequenced individuals, and, to increase power, most were tested in larger numbers of individuals (>80% of low-frequency coding variants in ~82 K Europeans via the exome chip, and ~90% of low-frequency non-coding variants in ~44 K Europeans via genotype imputation). The variants, genotypes, and association statistics from these analyses provide the largest reference to date of human genetic information relevant to T2D, for use in activities such as T2D-focused genotype imputation, functional characterization of variants or genes, and other novel analyses to detect associations between sequence variation and T2D.

Objective: To study relationship between androgen receptor (AR) CAG repeat polymorphism, insulin resistance (IR), β-cell function and other clinical/biochemical parameters in ethnic South Asian adults. A case (males with diabetes), control (males without diabetes) study, was conducted and 110 males were invited. Anthropometry, blood pressure and biochemical parameters (fasting Insulin, blood sugar, HbA1c and lipid profile) were measured. IR and β-cell function was calculated. A multiple-linear-regression analysis was performed, using number of AR CAG repeats as the continuous dependent variable., Results: Sample size was 100 (response rate-90.9%, cases-53). Mean age was 49.6 ± 10.7 years. CAG repeat length did not show any significant correlation with IR or β-cell function. In all males there was a significant correlation between number of AR CAG repeats and systolic blood pressure (r = 0.25; p = 0.016), diastolic blood pressure (r = 0.21; p = 0.045), total cholesterol (r = - 0.22; p = 0.037) and low-density lipoprotein cholesterol (r = - 0.22; p = 0.037). Only total cholesterol (β = - 4.41; p < 0.001) and estrogen (β = 2.25; p = 0.03) were significantly associated with number of AR CAG repeats in regression analysis. In conclusion, AR CAG repeat length did not show any significant correlation with IR or β-cell function. Positive association of AR CAG with systolic and diastolic blood pressure and negative association of AR CAG with total and low-density lipoprotein cholesterol deserves further attention.

Background: The use of peripheral locked screws has reduced glenoid baseplate failure rates in reverse shoulder arthroplasty. However, situations may arise when one or more non-locked screws may be preferred. We aimed to determine if different combinations of locked and non-locked screws significantly alter acute glenoid baseplate fixation in a laboratory setting., Materials and Methods: Twenty-eight polyurethane trabecular bone surrogates were instrumented with a center screw-type glenoid baseplate and fixated with various combinations of peripheral locked and non-locked screws (1-, 2-, 3- and 4-locked con). Each construct was tested through a 55° arc of abduction motion generating compressive and shear forces across the glenosphere. Baseplate micromotion (μm) was recorded throughout 10,000 cycles for each model., Results: All constructs survived 10,000 cycles of loading without catastrophic failure. One test construct in the 1-locked fixation group exhibited a measured micromotion >150 μm (177.6 μm). At baseline (p > 0.662) and following 10,000 cycles (p > 0.665), no differences were observed in baseplate micromotion for screw combinations that included one, two, three and four peripheral locked screws. The maximum difference in measured micromotion between the extremes of groups (1-locked and 4-locked) was 29 µm., Conclusions: Hybrid peripheral screw fixation using combinations of locked and non-locked screws provides secure glenoid baseplate fixation using a polyurethane bone substitute model. Using a glenosphere with a 10-mm lateralized center of rotation, hybrid baseplate fixation maintains micromotion below the necessary threshold for bony ingrowth., Level of Evidence: N/A/, basic science investigation.

Aims: Hypoglycaemia is a significant risk in insulin treated type 2 diabetes and has been associated with future risk of cardiovascular events. We compared the frequency of low-glucose events using continuous glucose monitoring (CGM) with that of self-reported hypoglycemic events at the end of the first and third years of the Treating to Target in Type 2 Diabetes Trial (4-T), which compared biphasic, prandial and basal insulin regimens added to sulfonylurea and metformin., Methods: CGM using a Medtronic Gold system was performed in a subgroup of 4-T participants. CGM detected low-glucose events were defined at thresholds of ≤3.0 (CGM3.0) and ≤2.2 (CGM2.2) mmol/l., Results: Of the 110 participants, 106 and 70 had CGM analysable data at the end of years 1 and 3 respectively. In both years, the frequency of CGM detected low glucose events was several fold higher than that of self-reported hypoglycaemia (symptoms with blood glucose less than 3.1mmol/l [<56mg/dl]). At the end of the first year, CGM3.0 and CGM2.2 mean (95%CI) event frequencies, expressed at events per participant per year, were 120 (85, 155) and 41 (21, 61) compared with 17 (8, 29) self-reported events during CGM, each p=0.001. The disparity at the end of the third year was similar., Conclusions: These data demonstrate the likely under-reporting of hypoglycaemia and of potential hypoglycaemia unawareness in clinical trials. The clinical implications of these findings need to be explored further (ISRCTN No ISRCTN51125379)., (Copyright © 2017. Published by Elsevier B.V.)

Background: The overall impact of American Shoulder and Elbow Surgeons (ASES) membership on volume of primary and revision procedures has not been evaluated. The purpose of this study was to examine the association between high-volume primary and revision arthroplasty surgeons and membership in the ASES using recent Medicare data., Methods: Data from 2014 for all providers performing primary shoulder arthroplasty ( Current Procedural Terminology codes 23470 and 23472) and revision procedures ( Current Procedural Terminology codes 23473 and 23474) were identified using the Medicare Physician and Other Supplier Public Use File for 2016. Providers were rank ordered on the basis of the total number of procedures performed and subdivided as ASES members and nonmembers., Results: ASES members composed 16% of all surgeons performing shoulder arthroplasty but performed 28% of primary arthroplasty and 63% of revision procedures. The mean number of procedures per provider was significantly greater for ASES members compared with non-ASES members (44.2 ± 30.7 vs. 21.4 ± 13.2; P  < .001); 70% of the 53 highest volume surgeons were ASES members and performed 71% of all primary and 89% of all revision shoulder arthroplasties among this group., Conclusion: ASES members represent the largest proportion of high-volume shoulder arthroplasty surgeons in the United States and perform a majority of all primary and revision arthroplasties among this group.

Background: The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures., Methods: We conducted a retrospective query of a single private payer insurance claims database using PearlDiver (Warsaw, IN, USA) from 2010 to 2014. Our search included the Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Medical comorbidities were also searched for through International Classification of Diseases codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, cirrhosis, depression, and chronic kidney disease (excluding end-stage renal disease). The reimbursement charges of the day of surgery, 90-day global period, and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted through analyses of variance or Kruskal-Wallis test., Results: Comorbidities did not have a significant effect on same-day reimbursements but instead caused a significant effect on the subsequent 89-day (interval) and 90-day reimbursements in the TSA and RSA cohorts. For TSA and RSA, the highest reimbursement costs during the 90-day period after surgery were seen with the diagnosis of hepatitis C, followed by atrial fibrillation and later chronic obstructive pulmonary disease. For hemiarthroplasty, the same was true in the following order: hepatitis C, cirrhosis, and atrial fibrillation., Conclusion: Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to delineate the time taken to achieve maximum improvement (plateau of recovery) and the degree of recovery observed at various time points (speed of recovery) for pain and function after arthroscopic rotator cuff repair., Methods: An institutional shoulder surgery registry query identified 627 patients who underwent arthroscopic rotator cuff repair between 2006 and 2015. Measured range of motion, patient satisfaction, and patient-reported outcome measures were analyzed for preoperative, 3-month, 6-month, 1-year, and 2-year intervals. Subgroup analysis was performed on the basis of tear size by retraction grade and number of anchors used., Results: As an entire group, the plateau of maximum recovery for pain, function, and motion occurred at 1 year. Satisfaction with surgery was >96% at all time points. At 3 months, 74% of improvement in pain and 45% to 58% of functional improvement were realized. However, only 22% of elevation improvement was achieved (P < .001). At 6 months, 89% of improvement in pain, 81% to 88% of functional improvement, and 78% of elevation improvement were achieved (P < .001). Larger tears had a slower speed of recovery for Single Assessment Numeric Evaluation scores, forward elevation, and external rotation. Smaller tears had higher motion and functional scores across all time points. Tear size did not influence pain levels., Conclusion: The plateau of maximum recovery after rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. At 3 months, approximately 75% of pain relief and 50% of functional recovery can be expected. Larger tears have a slower speed of recovery., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

To identify novel coding association signals and facilitate characterization of mechanisms influencing glycemic traits and type 2 diabetes risk, we analyzed 109,215 variants derived from exome array genotyping together with an additional 390,225 variants from exome sequence in up to 39,339 normoglycemic individuals from five ancestry groups. We identified a novel association between the coding variant (p.Pro50Thr) in AKT2 and fasting plasma insulin (FI), a gene in which rare fully penetrant mutations are causal for monogenic glycemic disorders. The low-frequency allele is associated with a 12% increase in FI levels. This variant is present at 1.1% frequency in Finns but virtually absent in individuals from other ancestries. Carriers of the FI-increasing allele had increased 2-h insulin values, decreased insulin sensitivity, and increased risk of type 2 diabetes (odds ratio 1.05). In cellular studies, the AKT2-Thr50 protein exhibited a partial loss of function. We extend the allelic spectrum for coding variants in AKT2 associated with disorders of glucose homeostasis and demonstrate bidirectional effects of variants within the pleckstrin homology domain of AKT2 ., (© 2017 by the American Diabetes Association.)

Background: Patient-reported outcome measures (PROMs) have become increasingly important in assessing clinical outcomes. However, acquisition of data at routine time intervals can be challenging. The ability of e-mail reminders to save follow-up intervals when office visits are missed is unknown., Materials and Methods: A retrospective review of a consecutive series of 186 shoulder surgical patients who underwent surgery between October 2, 2012, and July 2, 2013, was conducted. Simple Shoulder Test and 12-Item Short Form Health Survey scores were completed at preoperative visits using office-based tablet surveys. Patients were observed for completeness of PROMs at expected routine follow-up of 1 year and 2 years. When office visits were missed, e-mail reminders with links to online surveys were sent to patients without further incentives. Improvement in data acquisition achieved using e-mail reminders when patient follow-up was missed was assessed. The influence of the procedure performed was further analyzed to determine whether patients treated with different surgical procedures would be more compliant with PROM completion., Results: Use of e-mail reminders significantly increased the number of patients for whom complete follow-up data were obtained. Compared with tablet surveys completed during office visits alone, the addition of e-mail reminders increased the collection of complete PROM data (both 1- and 2-year follow-up) by 25.8% ( P  < .001). Similar findings were observed for total shoulder arthroplasty and arthroscopic rotator cuff repair patients (increased by 25.7% and 34.4%, respectively; P  < .001)., Conclusion: E-mail reminders serve as a mechanism to increase the completeness of follow-up data in the absence of in-office patient evaluation.

Background: Advancement in surgical techniques and implants has improved the ability to manage radial head and olecranon fractures. However, trends in management of these fractures are largely unstudied., Objective: This purpose of this study is to evaluate management trends for these common fractures., Methods: A retrospective review of a comprehensive Humana database was performed using Pearl Diver supercomputer (Warsaw, IN, USA) for radial head and neck (RHNF) and olecranon fractures (OF) between 2007 and 2014. Treatment methods including open reduction internal fixation (ORIF), radial head arthroplasty (RHA), and non-operative treatment were reviewed. Total reported incidence of office visits and utilization of each treatment modality were investigated. Sub-analysis with stratification by age 15-74 and greater than 75-years was performed for OF., Results: A total of 10,609 OF and 20,400 RHNF were identified between 2007 and 2014. A significant trend increase in the annual incidence of RHNF (266 cases/year, p<0.001) and OF (133.9 cases/year, p=0.001) was observed. A significant trend increase in annual percent utilization of RHA (0.22% per year, p=0.011) and a significant trend decrease in the annual percent utilization of ORIF (-1.0% per year, p=0.004) and non-operative management (-0.53% per year, p=0.046) was observed for RHNF. A significant trend increase was observed in percent utilization (0.40% per year, p=0.022) for OF non-operative management, especially in patients over 75 years (66% per year, p=0.034)., Conclusion: The percentage of patients being treated with RHA is increasing. Non-operative management of OF has increased, specifically in the patients who are over 75 years.

Background: Locked anterior shoulder (LAS) with static instability and anterior glenoid bone loss is challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS with classically indicated RSA., Methods: A retrospective case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months, and median age was 76 years. Motion, outcome assessments, and postoperative radiographs were compared., Results: Preoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common (P = .05) in the control group (26%) than in the LAS group (6.3%). Larger glenospheres were used more often (P = .001) in the LAS group (75%) than in the control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, the control group had significantly better elevation and functional outcome scores. With the exception of flexion and Simple Shoulder Test score, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS patients and 9% of controls (P = .023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated., Conclusion: Patients with LAS treated with RSA can anticipate improvements in pain and function by use of larger glenospheres, often without the need for glenoid bone grafting. Worse postoperative motion and function and a higher incidence of acromion stress fracture may be expected., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Diabetes in pregnancy is a global problem. Technological innovations present exciting opportunities for novel approaches to improve clinical care delivery for gestational and other forms of diabetes in pregnancy., Objective: To perform an updated and comprehensive systematic review and meta-analysis of the literature to determine whether telemedicine solutions offer any advantages compared with the standard care for women with diabetes in pregnancy., Methods: The review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Randomized controlled trials (RCT) in women with diabetes in pregnancy that compared telemedicine blood glucose monitoring with the standard care were identified. Searches were performed in SCOPUS and PubMed, limited to English language publications between January 2000 and January 2016. Trials that met the eligibility criteria were scored for risk of bias using the Cochrane Collaborations Risk of Bias Tool. A meta-analysis was performed using Review Manager software version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration)., Results: A total of 7 trials were identified. Meta-analysis demonstrated a modest but statistically significant improvement in HbA1c associated with the use of a telemedicine technology. The mean HbA1c of women using telemedicine was 5.33% (SD 0.70) compared with 5.45% (SD 0.58) in the standard care group, representing a mean difference of -0.12% (95% CI -0.23% to -0.02%). When this comparison was limited to women with gestational diabetes mellitus (GDM) only, the mean HbA1c of women using telemedicine was 5.22% (SD 0.70) compared with 5.37% (SD 0.61) in the standard care group, mean difference -0.14% (95% CI -0.25% to -0.04%). There were no differences in other maternal and neonatal outcomes reported., Conclusions: There is currently insufficient evidence that telemedicine technology is superior to standard care for women with diabetes in pregnancy; however, there was no evidence of harm. No trials were identified that assessed patient satisfaction or cost of care delivery, and it may be in these areas where these technologies may be found most valuable., Competing Interests: Conflicts of Interest: None declared., (©Wai-Kit Ming, Lucy H Mackillop, Andrew J Farmer, Lise Loerup, Katy Bartlett, Jonathan C Levy, Lionel Tarassenko, Carmelo Velardo, Yvonne Kenworthy, Jane E Hirst. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.11.2016.)

Periprosthetic humerus fractures are relatively uncommon occurrence that can be difficult to manage nonoperatively. Locking plate technology has enhanced the surgical management of these fractures. However, adequate fixation around the stem remains of some concern. We describe an osteosynthesis technique using a locking plate utilizing eccentrically placed screw holes to place "skive screws" in the proximal end of the plate to achieve fixation around the stem of the implant. A clinical series of 5 consecutive patients treated with this technique is presented with an average follow-up of 29 months (range, 12-48). Two additional patients had less than 1-year follow-up. All patients demonstrated fracture healing. Functional outcomes were limited with only 1 patient achieving forward elevation above 90 degree, and the average American Shoulder and Elbow Surgeons Function score was 28. Pain relief was nearly uniform with an average visual analog scale pain score of 0.5.

Background: Utilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients., Methods: We performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed., Results: Utilization of TEA remained unchanged (P = .9530) despite a growing Medicare population (P = .0201). There was a significant decline in annual TEA utilization for RA (P = .002) and DHNU (P = .003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU (P < .001). A significant, strong negative correlation was found for office visit coding and TEA use in RA (r = -0.850; P = .008) and DHNU (r = -0.902; P = .002)., Conclusion: From 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeon's comfort with improved fracture fixation options., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The genetic architecture of common traits, including the number, frequency, and effect sizes of inherited variants that contribute to individual risk, has been long debated. Genome-wide association studies have identified scores of common variants associated with type 2 diabetes, but in aggregate, these explain only a fraction of the heritability of this disease. Here, to test the hypothesis that lower-frequency variants explain much of the remainder, the GoT2D and T2D-GENES consortia performed whole-genome sequencing in 2,657 European individuals with and without diabetes, and exome sequencing in 12,940 individuals from five ancestry groups. To increase statistical power, we expanded the sample size via genotyping and imputation in a further 111,548 subjects. Variants associated with type 2 diabetes after sequencing were overwhelmingly common and most fell within regions previously identified by genome-wide association studies. Comprehensive enumeration of sequence variation is necessary to identify functional alleles that provide important clues to disease pathophysiology, but large-scale sequencing does not support the idea that lower-frequency variants have a major role in predisposition to type 2 diabetes.

Background: Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures., Methods: A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up., Results: At an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6 mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome., Conclusions: The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Glenoid component loosening remains a common mode of failure for total shoulder arthroplasty and has inspired improvements in implant design, instrumentation, and surgical technique. The purpose of this manuscript was to evaluate the incidence of radiolucent lines and glenoid seating on initial postoperative radiographs using a modern pegged-glenoid design, instrumentation, and surgical technique., Materials and Methods: We performed a retrospective analysis of a consecutive series of 100 pegged-glenoid total shoulder replacements. In cases of excessive glenoid version, the glenoid was asymmetrically reamed to recreate more normal version. Initial postoperative radiographs were evaluated for the presence of radiolucent lines and completeness of glenoid seating. The preoperative glenoid version measured on axial computed tomography (CT) scans was used to compare differences in version among those with complete and incompletely seated glenoids., Results: The rate of radiolucent lines observed on postoperative radiographs was 0%. Complete glenoid seating (Grade A) was observed in 81 patients (observer 1) and 82 patients (observer 2). Measurements of preoperative CT scans found a higher percentage of abnormal glenoid version for incompletely seated glenoids (47%) than completely seated glenoids (34%) but no significant difference (P = 0.327). The mean preoperative glenoid retroversion for incompletely seated glenoids was 12.1° and 9.1° for completely seated glenoids (P = 0.263)., Conclusions: Modern surgical techniques, surgical instrumentation, and peg glenoid design have facilitated the ability to eliminate radiolucent lines on initial postoperative radiographs with high rates of complete seating of glenoid components. Incomplete seating may be related to incomplete correction of glenoid version.

Background: Surgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population., Methods: We retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated., Results: Within the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume (P = .119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% (P < .001). The utilization rate decreased significantly for HA from 52% to 39% (P < .001), increased significantly for RSA from 11% to 28% (P < .001), and did not change significantly for ORIF (P = .164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%)., Conclusion: From 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The prevalence of gestational diabetes mellitus (GDM) is rising in the UK. Good glycaemic control improves maternal and neonatal outcomes. Frequent clinical review of patients with GDM by healthcare professionals is required owing to the rapidly changing physiology of pregnancy and its unpredictable course. Novel technologies that allow home blood glucose (BG) monitoring with results transmitted in real time to a healthcare professional have the potential to deliver good-quality healthcare to women more conveniently and at a lower cost to the patient and the healthcare provider compared to the conventional face-to-face or telephone-based consultation. We have developed an integrated GDm-health management system and aim to test the impact of using this system on maternal glycaemic control, costs, patient satisfaction and maternal and neonatal outcomes compared to standard clinic care in a single large publicly funded (National Health Service (NHS)) maternity unit., Methods and Analysis: Women with confirmed gestational diabetes in a current pregnancy are individually randomised to either the GDm-health system and half the normal clinic visits or normal clinic care. Primary outcome is mean BG in each group from recruitment to delivery calculated, with adjustments made for number of BG measurements, proportion of preprandial and postprandial readings and length of time in study, and compared between the groups. The secondary objective will be to compare the two groups for compliance to the allocated BG monitoring regime, maternal and neonatal outcomes, glycaemic control using glycated haemoglobin (HbA1c) and other BG metrics, and patient attitudes to care assessed using a questionnaire and resource use., Ethics and Dissemination: Thresholds for treatment, dietary advice and clinical management are the same in both groups. The results of the study will be published in a peer-reviewed journal and disseminated electronically and in print., Trial Registration Number: NCT01916694; Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Total shoulder arthroplasty (TSA) has repeatedly been shown to be an effective and durable treatment option for end-stage arthritis with good long-term survivorship. Whereas pain relief is typically the primary goal, improvements in range of motion are typically expected as well. The factors that influence postoperative motion have not been well characterized. The purpose of the study was to examine the factors that influence ultimate postoperative motion after TSA., Methods: A retrospective review was conducted of prospectively collected data of 230 patients with minimum 1-year follow-up after TSA for end-stage arthropathy with an intact rotator cuff. Analysis was focused on factors that may correlate with postoperative measured forward flexion, abduction, external rotation, and internal rotation. Included in this analysis was perception of motion, age, body mass index (BMI), comorbidities (smoking, diabetes, osteoporosis, hypercholesterolemia, inflammatory arthritis, and thyroid disease), and number of comorbidities., Results: Preoperative motion in all directions was predictive of postoperative motion for forward flexion (R = 0.235; P < .001), abduction (R = 0.363; P < .001), external rotation (R = 0.325; P < .001), and internal rotation (R = 0.213; P = .002). BMI and diabetes both negatively correlated with internal rotation (R = -0.134, P = .40 and R = -0.196, P = .003, respectively). Individual and total number of comorbidities were not predictive of postoperative motion. The patient's perception of preoperative motion also did not correlate with postoperative motion., Conclusions: Preoperative range of motion before TSA is most predictive of final motion achieved. Individual and total number of comorbidities are not predictive of postoperative motion. Patients with high diabetes and increased BMI have limited postoperative internal rotation., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The present study aims to evaluate the relationship between physical activity and sexual dysfunction amongst an ethnic South Asian population living in the United Kingdom and compare the association with that of the native Caucasian population., Methods: Twenty-five general practitioner clinics from eight primary care trusts in the United Kingdom collaborated in the Oxford Sexual Dysfunction Study. In each practice, a sample of diabetic and non-diabetic patients of European/Europid and South Asian origin were invited for the study. Erectile dysfunction (ED) was assessed using a five-item version of the International Index of Erectile Function. Premature ejaculation (PE) was diagnosed using the premature ejaculation diagnostic tool. Libido was assessed by asking participants to grade their desire for sexual activity. Physical activity during the past week was assessed using the short version of the International Physical Activity Questionnaire (IPAQ). A binary logistic regression analysis was performed in all adults, Europids and South Asians with 'presence of ED' as the dichotomous dependent variable (0 = ED absent; 1 = ED present) and age, diabetes status, physical activity, ethnicity, current smoking and use of antihypertensive medications as the independent variables., Results: Sample size was 510, and mean age was 56.9 ± 9.7 years. There were 63.9 % (n = 326) Europid males in the study population. The prevalence of ED was 64.5 % and it was significantly higher in men with diabetes than in those without diabetes (84.4 vs. 49.0 %, p < 0.001). The overall prevalence of PE was 28.8 %, (with diabetes 32.6 %, without diabetes 25.8 %; p = 0.109). Reduced libido was reported by 26.9 % of study participants (with diabetes 32.8 %, without diabetes 22.0 %; p < 0.01). The median (IQR) total physical activity of the study population was 2373 (3612) MET-min/week. In the IPAQ categorical score, 36.8 % (n = 184/434) males were 'highly active', and 17.8 % (n = 89/434) were 'inactive'. In all adults, age (OR: 1.06), South Asian ethnicity (OR: 1.40), physical inactivity (OR: 1.62) and presence of diabetes (OR: 3.90) all were associated with significantly increased risk of developing ED. A similar result was observed in Europids but not in South Asians., Conclusions: Erectile dysfunction was associated with physical inactivity, mainly in Europid males, irrespective of diabetes status. This association was not observed in South Asian males with or without diabetes.

Background: Reverse shoulder arthroplasty has seen increased use for management of complex proximal humeral fractures in the elderly. Recent evidence has shown that tuberosity healing leads to improved active range of motion and functional outcomes. The purpose of this study was to report on the radiographic and clinical outcomes of a consecutive series of patients having undergone reverse shoulder arthroplasty for fracture utilizing the "black and tan" method--a hybrid cementation-impaction grafting technique that uses autogenous cancellous bone graft to create an interface between the proximal cement mantle and the area of tuberosity repair., Methods: Twenty-five patients (average age, 77 years; range, 63-88 years) were included in the analysis with a mean follow-up of 17 months. All patients underwent reverse shoulder arthroplasty for a complex proximal humerus fracture using the black and tan technique., Results: The tuberosity healing rate was 88%. At final follow-up, mean active elevation was 117° ± 23°, mean abduction was 86° ± 16°, and mean external rotation was 29° ± 18°. External rotation strength averaged 4.9 ± 0.2. The Simple Shoulder Test and Single Assessment Numeric Evaluation scores averaged 7 and 76, respectively. The mean American Shoulder and Elbow Surgeons total score was 71; visual analog scale score for pain, 2; and visual analog scale score for function, 7. Of the 25 patients, 21 (84%) rated their satisfaction with the surgery as excellent or good., Conclusions: The black and tan technique together with standard suture repair and an implant with features that support tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after reverse shoulder arthroplasty for fracture., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Glenoid bone loss is commonly observed during primary and revision reverse shoulder arthroplasty. Glenoid baseplates are often implanted with incomplete glenoid bone support. The purpose of this study was to evaluate the glenoid component fixation of the glenoid baseplate with variable amounts of incomplete coverage., Methods: Twenty-eight polyurethane trabecular bone surrogates were instrumented with the same center screw-type glenoid baseplate with 4 peripheral 5.0-mm locking screws in a glenoid bone loss model consisting of 25%, 50%, 75%, and 100% coverage. Each construct was tested through a 55° arc of motion with both compressive and shear forces across the glenosphere. Baseplate micromotion was recorded throughout 10,000 cycles for each model., Results: There was no significant difference in baseline micromotion between the 4 experimental groups (P = .099). In the 25% baseplate coverage group, 3 of 7 exhibited micromotion above the 150-μm threshold (624.5, 469.1, and 712.1 μm) during cyclic loading. After 10,000 cycles of loading, the 25% coverage group exhibited significantly more micromotion than the 50% (P = .049), 75% (P = .026), and 100% (P = .040) coverage groups. There was no significant difference between the 100%, 75%, and 50% coverage groups (P = 1.00)., Conclusions: Glenoid baseplate fixation in the setting of glenoid bone loss is no different when 50%, 75%, or 100% of the baseplate is supported by glenoid bone. Bone loss resulting in only 25% coverage results in significantly greater micromotion, often above the 150-μm threshold., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) are routinely performed in patients older than 80 years. Often unaware of the differences between the 2 procedures, patients may expect similar outcomes from these procedures. This article reports the outcomes of primary TSA and RSA in patients older than 80 years, with attention directed toward differences in outcomes between the procedures. The authors evaluated a consecutive series of patients who were at least 80 years old and were treated with primary shoulder arthroplasty and had a minimum follow-up of 2 years. Of these patients, 18 underwent primary TSA for osteoarthritis and 33 underwent primary RSA for rotator cuff tear arthropathy. Pain scores, function scores, and range of motion were evaluated preoperatively and at final follow-up. Perioperative and postoperative complications, transfusion rates, length of stay, and subjective satisfaction with the outcome were reported. In these patients, TSA and RSA were similarly effective in improving pain scores, functional scores, and range of motion measurements. Patients who had TSA reported significantly greater satisfaction with surgery and had superior American Shoulder and Elbow Society total and function scores, forward elevation, and external rotation, but similar net improvement from preoperative levels. Although no significant differences were shown in complications, length of stay, or requirement for transfusion, patients treated with RSA had higher rates of transfusion and postoperative complications. Both procedures were similarly effective treatments for patients older than 80 years and showed similar improvements in pain, function, and motion. Patients undergoing RSA were less likely to have good to excellent results, with higher complication and transfusion rates., (Copyright 2015, SLACK Incorporated.)

Background: Self-administered questionnaires provide a better alternative to disclose sensitive information in sexual health research. We describe the factors that determine the positive response (initial recruitment) to an initial invitation and subsequent completion of study to a postal questionnaire on sexual dysfunction., Methods: South Asians (SA) and Europids with and without diabetes (DM) were recruited from GP clinics in UK. Men who returned the properly filled consent form ('recruited-group') were sent the questionnaire and those who returned it were considered as the 'completed-group'. Index of Multiple Deprivation Scores (IMDs) were generated using UK postcodes. We calculated the recruitment rate and completion rate of the recruited and the study-completed groups respectively., Results: Total approached sample was 9100 [DM: 2914 (32%), SA: 4563 (50.1%)]. Recruitment rate was 8.8% and was higher in Europids and in patients with DM. Mean IMDs for the recruited group was 20.9 ± 11.9, and it was higher among recruited SA compared to Europids (p < 0.001). Mean IMDs was higher in the recruited group compared to non-recruited (p < 0.01). All four recruited groups (SA/Europid and DM/non-DM) had lower IMDs compared to non-recruited. Completion rate was 71.5% (n 544) (SA: 62.3%, Europids: 77.4%; p < 0.05)., Conclusion: Recruitment for postal sexual health surveys is positively influenced by presence of investigated disease, older age, being from lesser deprived areas and Europid ethnicity. Furthermore, Europids were more likely to complete survey than South Asians irrespective of disease status.

Background: Recovery of functional internal rotation after primary shoulder arthroplasty is essential to perform many important activities of daily living. Functional internal rotation is typically reported as it relates to clinical examination findings of motion (posterior reach) and lift-off or belly-press tests. A more detailed evaluation of functional recovery of internal rotation after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) is needed., Methods: A retrospective review of patients treated with primary TSA (n = 132) and RSA (n = 91) with a minimum 2-year follow-up was performed. Subanalysis of revision RSA (n = 24) and primary RSA was performed. Active range of motion, subjective internal rotation motion, manual internal rotation strength, and specific questions related to internal rotation function isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) functional questionnaires were reviewed., Results: Compared with RSA, TSA patients could more likely reach the small of the back (SST) and wash the back/fasten bra (ASES). Active internal rotation motion, SST score, ASES score, and subjective internal rotation were greater after TSA. No significant difference was observed with respect to managing toileting between cohorts. Revision RSA patients were less likely to be able to wash the back/fasten bra (ASES) and easily manage toileting (ASES) compared with primary RSA patients., Conclusion: Primary anatomic shoulder arthroplasty yields greater functional internal rotation than does primary RSA, with either procedure being effective at managing toileting. Patient education regarding activities of daily living related to internal rotation can be predicted., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Management of an infected shoulder arthroplasty remains challenging. Treatment goals include resolution of the infection, improvement in pain, and restoration of function. Two-stage revision with an antibiotic spacer and subsequent revision has shown variable success in achieving these goals. The practice of using a hemiarthroplasty and coating the stem with antibiotic cement without cementing the implant to the humerus (functional antibiotic spacer) during the first stage has the potential to achieve treatment goals without the need for a second revision. The goal of this study was to examine the outcomes of a maintained functional antibiotic spacer without a second revision for the management of infected shoulder arthroplasty. Fourteen patients with an infected shoulder arthroplasty underwent implantation of a functional antibiotic spacer, extensive surgical debridement, and a minimum of 6 weeks of treatment with postoperative intravenous antibiotics. The 9 patients who elected not to undergo revision surgery were included in this analysis. Pain scores, functional outcome scores, range of motion, strength, and patient satisfaction were measured for these patients at last follow-up and compared with preoperative scores. At an average follow-up of 25 months (range, 12-48 months), significant improvements were observed in functional outcome scores, shoulder abduction, and elevation, with a trend toward improvement in pain scores. One patient was unsatisfied with the result. No recurrent infection, progressive radiolucency, or change in position of the functional antibiotic spacer was observed. A functional antibiotic spacer effectively manages the infected shoulder arthroplasty while achieving significant improvements in function and motion. Patient satisfaction was high, with a relatively low rate of conversion to second-stage revision., (Copyright 2015, SLACK Incorporated.)

Background: Cerebral oximetry (rSO2) has emerged as an important tool for monitoring of cerebral perfusion during surgery. High rates of cerebral desaturation events (CDEs) have been reported during surgery in the beach chair position. However, correlations have not been made with blood pressure measured at the cerebral level. The purpose of this study was to examine the correlations between brachial noninvasive blood pressure (NIBP) and estimated temporal mean arterial pressure (eTMAP) during CDEs in the beach chair position., Methods: Fifty-seven patients underwent elective shoulder surgery in the beach chair position. Values for eTMAP, NIBP, and rSO2 were recorded supine (0°) after induction and when a CDE occurred in the 70° beach chair position. Twenty-six patients experienced 45 CDEs, defined as a 20% drop in rSO2 from baseline., Results: Median reduction in NIBP, eTMAP, and rSO2 from baseline to the CDE were 48.2%, 75.5%, and 33.3%, respectively. At baseline, there was a significant weak negative correlation between rSO2 and NIBP (rs = -0.300; P = .045) and no significant association between rSO2 and eTMAP (rs = -0.202; P = .183). During CDEs, there were no significant correlations between rSO2 and NIBP (rs = -0.240; P = .112) or between rSO2 and eTMAP (rs = -0.190; P = .212). No significant correlation between the decrease in rSO2 and NIBP (rs = 0.064; P = .675) or between rSO2 and eTMAP (rs = 0.121; P = .430) from baseline to CDE was found., Conclusion: NIBP and eTMAP are unreliable methods for identifying a CDE in the beach chair position. Cerebral oximetry provides additional information to the values obtained from NIBP and eTMAP, and all should be considered independently and collectively., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aims/hypothesis: The aim of this study was to investigate the incremental and proportional effect of a sulfonylurea on insulin secretion rates at low, elevated and high blood glucose, using parallel groups with ascending or descending glucose steps to minimise potential biases of a single stepped clamp order., Methods: Following 14 days on placebo or glibenclamide (2.5 mg) tablets twice daily, separated by 14 days washout, 19 type 2 diabetic patients had ascending or descending three-step hyperinsulinaemic glucose clamps at 4, 8 and 12 mmol/l. C-peptide secretion was estimated by two-compartment C-peptide deconvolution., Results: Patients in the ascending glucose steps group (n = 10) had mean (SD) age of 60.3 (6.5) years, BMI of 29.8 (4.9) kg/m(2) and fasting glucose on diet alone of 10.6 (2.9) mmol/l; while those in the descending glucose steps group (n = 9) had mean age of 58.2 (8.0) years, BMI of 30.5 (5.4) kg/m(2) and fasting glucose on diet alone of 9.8 (2.2) mmol/l. The geometric means (95% CI) of C-peptide secretion rates on placebo for glucose at 4.0, 8.0 and 12.0 mmol/l were 63 (46, 86), 143 (105, 195) and 205 (149, 281) pmol/min, respectively. On glibenclamide, this increased by 140 (99, 181), 126 (85, 167) and 158 (117, 199) pmol/min, respectively (p < 0.001 vs placebo). The absolute increment was significant (p < 0.001) and independent of clamp glucose concentration (p = 0.54). The proportional increase was greater at 4 mmol/l: 2.8-fold (2.4, 3.2), compared with 1.8-fold (1.5, 2.0) and 1.7-fold (1.4, 1.9) at 8 and 12 mmol/l, respectively (p < 0.001)., Conclusions/interpretation: At low-normal glucose, glibenclamide exerted a disproportionate effect on insulin secretion. This study highlights the risks of hypoglycaemia when aiming for tight glucose control on this agent.

The increase in gestational diabetes mellitus (GDM) is challenging maternity services. We have developed an interactive, smartphone-based, remote blood glucose (BG) monitoring system, GDm-health. The objective was to determine women's satisfaction with using the GDm-health system and their attitudes toward their diabetes care. In a service development program involving 52 pregnant women (September 2012 to June 2013), BG was monitored using GDm-health from diagnosis until delivery. Following birth, women completed a structured questionnaire assessing (1) general satisfaction, (2) equipment issues, and (3) relationship with the diabetes care team. Responses were scored on a 7-point Likert-type scale. Reliability and validity of the questionnaire were assessed using statistical methods. Of 52 women, 49 completed the questionnaire; 32 had glucose tolerance test confirmed GDM (gestation at recruitment 29 ± 4 weeks (mean ± SD), and 17 women previous GDM recommended for BG monitoring (18 ± 6 weeks). In all, 45 of 49 women agreed their care was satisfactory and the best for them, 47 of 49 and 43 of 49 agreed the equipment was convenient and reliable respectively, 42 of 49 agreed GDm-health fitted into their lifestyle, and 46 of 49 agreed they had a good relationship with their care team. Written comments supported these findings, with very positive reactions from the majority of women. Cronbach's alpha was .89 with factor analysis corresponding with question thematic trends. This pilot demonstrates that GDm-health is acceptable and convenient for a large proportion of women. Effects on clinical and economic outcomes are currently under investigation in a randomized trial (clinicaltrials.gov NCT01916694)., (© 2014 Diabetes Technology Society.)

Background: Estimation of cerebral perfusion pressure during elective shoulder surgery in the beach chair position is regularly performed by noninvasive brachial blood pressure (NIBP) measurements. The relationship between brachial mean arterial pressure and estimated temporal mean arterial pressure (eTMAP) is not well established and may vary with patient positioning. Establishing a ratio between eTMAP and NIBP at varying positions may provide a more accurate estimation of cerebral perfusion using noninvasive measurements., Methods: This prospective study included 57 patients undergoing elective shoulder surgery in the beach chair position. All patients received an interscalene block and general anesthesia. After the induction of general anesthesia, values for eTMAP and NIBP were recorded at 0°, 30°, and 70° of incline., Results: A statistically significant, strong, and direct correlation between NIBP and eTMAP was found at 0° (r = 0.909, P ≤ .001), 30° (r = 0.874, P < .001), and 70° (r = 0.819, P < .001) of incline. The mean ratios of eTMAP to NIBP at 0°, 30°, and 70° of incline were 0.939 (95% confidence interval [CI], 0.915-0.964), 0.738 (95% CI, 0.704-0.771), and 0.629 (95% CI, 0.584-0.673), respectively. There was a statistically significant decrease in the eTMAP/NIBP ratio as patient incline increased from 0° to 30° (P < .001) and from 30° to 70° (P < .001)., Conclusion: The eTMAP-to-NIBP ratio decreases as an anesthetized patient is placed into the beach chair position. Awareness of this phenomenon is important to ensure adequate cerebral perfusion and prevent hypoxic-related injuries., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Whereas patient expectations after anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) relate to sustained improvements in pain, function, and motion, the time necessary to reach these goals is unclear. Our purpose was to investigate the speed of recovery and to compare the effectiveness of primary TSA and RSA., Methods: We analyzed (preoperative, 3 month, 6 month, 1-year, and 2-year scores) pain scores, functional scores, and motion for 122 patients treated with primary RSA and 166 patients treated with primary TSA with a minimum of 1 year of follow-up. Comparisons were made to determine the effectiveness of treatment, time required to reach a plateau in improvement, and percentage of overall improvement at 3 and 6 months., Results: Significant improvements were observed for both TSA and RSA at all intervals (P < .001), except with internal rotation for RSA. Pain relief was rapid after both TSA and RSA. TSA patients reached a consistent plateau for pain and function by 6 months and for shoulder elevation by 1 year. RSA patients demonstrated variability with multiple false plateau points. By 6 months, TSA patients had achieved 90% to 100% of functional improvement, whereas RSA patients reached 72% to 91%. The effectiveness of TSA was greater than that of RSA for all measures with the exception of elevation and abduction., Conclusion: Whereas patients treated with primary TSA and RSA can expect rapid improvements in pain, those treated with TSA can anticipate a more consistent and effective recovery of pain, function, and shoulder rotation. Patients receiving RSA can expect a variable length of recovery with greater improvements in forward elevation and abduction., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Gestational diabetes mellitus (GDM) is defined as new onset or recognition of glucose intolerance in pregnancy. Evidence supports tight blood glucose regulation to prevent adverse maternal and fetal outcomes. Finger-prick blood glucose (BG) testing with frequent clinic review remains the most common method of managing diabetes in pregnancy. The prevalence of GDM is rising globally, pressuring resource-limited services. We have developed an intuitive, interactive, reliable, and accurate management system to record BG measurements and deliver management of GDM remotely. Following an initial scoping phase, a prototype software application was developed using an Android smartphone with BG meter linkage via Bluetooth. A custom website was built for clinician review of the data transmitted by the smartphone. After system refinement, further evaluation was undertaken for usability and reliability in a 48-patient service development project. Women used the system for an average of 13.1 weeks. In all, 19 686 BG measures were transmitted, 98.6% of which had a meal tag. A total of 466 text messages were transmitted. A mean of 30 BG readings per woman per week were transmitted, and 85% of women submitted the minimum requirement of 18 readings per week. We have developed a novel, real-time, smartphone-based BG monitoring management system that allows clinician review of real-time patient-annotated BG results. Results indicate high usage and excellent compliance by women. Robust clinical, economic, and satisfaction evaluations are required. To address these requirements, we are currently conducting a randomized controlled pilot trial., (© 2014 Diabetes Technology Society.)

Background: The accuracy of reproducing a surgical plan during shoulder arthroplasty is improved by computer assistance. Intraoperative navigation, however, is challenged by increased surgical time and additional technically difficult steps. Patient-matched instrumentation has the potential to reproduce a similar degree of accuracy without the need for additional surgical steps. The purpose of this study was to examine the accuracy of patient-specific planning and a patient-specific drill guide for glenoid baseplate placement in reverse shoulder arthroplasty., Methods: A patient-specific glenoid baseplate drill guide for reverse shoulder arthroplasty was produced for 14 cadaveric shoulders based on a plan developed by a virtual preoperative 3-dimensional planning system using thin-cut computed tomography images. Using this patient-specific guide, high-volume shoulder surgeons exposed the glenoid through a deltopectoral approach and drilled the bicortical pathway defined by the guide. The trajectory of the drill path was compared with the virtual preoperative planned position using similar thin-cut computed tomography images to define accuracy., Results: The drill pathway defined by the patient-matched guide was found to be highly accurate when compared with the preoperative surgical plan. The translational accuracy was 1.2 ± 0.7 mm. The accuracy of inferior tilt was 1.2° ± 1.2°. The accuracy of glenoid version was 2.6° ± 1.7°., Conclusion: The use of patient-specific glenoid baseplate guides is highly accurate in reproducing a virtual 3-dimensional preoperative plan. This technique delivers the accuracy observed using computerized navigation without any additional surgical steps or technical challenges., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)