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Background: The purpose of this study is to characterize National Institutes of Health (NIH) funding for rotator cuff research and evaluate the impact of orthopedic surgeons on this portfolio. Methods: The NIH’s Research Portfolio Online Reporting Tools Expenditures and Results database was queried for “rotator cuff repair” or “rotator cuff tear” from the 2011 to 2021 fiscal years. Compound annual growth rates were calculated and grants were categorized by basic, clinical, or translational research. Funding totals were compared by Principal Investigator (PI) and grant characteristics. Results: A total of 52 grants were awarded to 38 PIs between 2011 and 2021, totaling $40,156,859. Annual NIH funding for rotator cuff tear and rotator cuff repair increased by a Compound annual growth rate of 11.0% from 2011 to 2021, compared to 3.4% for the total NIH budget. Orthopedic surgeon-scientists received $9,208,212 (22.9%), most commonly through R01 (80.5%) and K08 (7.1%) mechanisms. No significant difference in funding was found by PI sex (P = .332), degree (P = .460), academic rank (P = .118), or researcher type (P = .227). Professors had a higher h-index than associate and assistant professors (P = .001). Orthopedic surgeon-scientists had a higher h-index (mean 36.3 ± 9.4) compared to clinician-scientists (mean 8.0 ± 1.4) and research-scientists (35.5 ± 40.7) (P = .044). Clinical topics receiving the highest funding were rehabilitation (23.9%), diagnosis, (22.3%) and surgical technique (14.8%). Orthopedic surgeon-scientists acquired funding for diagnosis (57.1%), rehabilitation (17.0%), and surgical technique (14.5%). Discussion: While NIH funding for rotator cuff research is growing, orthopedic surgeon representation is low. Future studies should evaluate barriers to obtaining funding for orthopedic surgeon-scientists.

Massive irreparable rotator cuff tears (RCTs) are a commonly encountered orthopedic condition that can be difficult to treat. Several techniques have been described to manage these tears, with the implantable subacromial balloon spacer being one of the most recent. The device, which has only been approved for clinical use in the United States since 2021, functions by resisting the superior humeral head migration seen in the setting of massive RCTs and restoring normal shoulder biomechanics, as corroborated by cadaveric studies. However, results regarding clinical outcomes have been mixed to date, and further high-quality studies are needed to define the optimal use of the subacromial balloon spacer in the treatment of massive irreparable RCTs.

Background:. Previous reports found that 40% of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 and 47% of those published from 2001 to 2013 were of high quality. The purpose of this study was to assess the quality of RCTs published from 2014 to 2022 in JBJS and to compare these findings with those of prior analyses in order to identify trends over time and areas for continued improvement. Methods:. PubMed was searched for the term “randomized controlled trial” to identify studies published in JBJS from 2014 to 2022. Each included RCT was evaluated with use of the Detsky score and a risk-of-bias assessment modified from the Cochrane tool. These evaluations were then compared with previous evaluations of RCTs from the 1988 to 2000 and 2001 to 2013 periods with use of independent-sample t tests. A transformed Detsky score of >75% and a modified risk-of-bias score of ≥8 were defined as being indicative of high quality. Results:. A total of 218 RCTs were published in JBJS from 2014 to 2022. An a priori sample size was calculated in 183 studies (83.9%). A total of 152 (83.1%) of the 183 studies enrolled the calculated number of patients, of which 126 (82.9%) maintained an adequate number at the time of final follow-up. Most RCTs were conducted at a single center (146 of 218; 67%), evaluated a surgical intervention (162 of 218; 74%), and reported positive results (142 of 218; 65%). The mean transformed Detsky score was 85% ± 10% (95% confidence interval, 83.7% to 86.3%), with 82% of trials (179 of 218) scored as high quality. The mean transformed Detsky score from 2014 to 2022 was higher than that from 1988 to 2000 and that from 2001 to 2013 (85% versus 76% and 68%, respectively; p < 0.001). The mean modified risk-of-bias score was 7 ± 1, with 42% of trials (92 of 218) scored as high quality. RCTs published from 2014 to 2022 had a higher mean modified risk-of-bias score than those published from 2001 to 2013 (7 ± 1 versus 6 ± 1; p < 0.001). Compared with the 2001 to 2013 and 2014 to 2022 periods, the 1988 to 2000 period had a greater proportion of trials that reported positive results (51% and 65% versus 82%, respectively; p < 0.001) and that included data from multiple centers (31% and 33% versus 67%; p < 0.001). Conclusions:. The quality of RCTs published in JBJS from 2014 to 2022 has improved from that reported previously, as demonstrated by the increases in the modified risk-of-bias score and transformed Detsky score from prior periods. This may be the result of journal policies such as the requirements of CONSORT adherence and prospective trial registration. Investigators should focus on improving the clarity of reporting, limiting attrition bias, and making efforts to blind support staff in order to increase the quality of future RCTs. Clinical Relevance:. Improving the quality of RCTs is crucial given their potential to influence current clinical practice.

Background: Despite the rising incidence of anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) among surgeons, little is known about the learning curve associated with these procedures. The purpose of this systematic review was to (1) identify the learning curves associated with ATSA and RTSA, (2) evaluate the effect of the learning curves on clinical outcomes, and (3) determine the number of cases needed to achieve proficiency. Methods: Four online databases [PubMed (NLM), MEDLINE (OVID), Cochrane Library (Wiley), and Scopus (Elsevier)] were systematically searched and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The search included results from the inception of each database to May 18, 2022. Data regarding study characteristics, patient demographics, learning curve analyses, patient reported outcome measures, range of motion, complication rates, and reoperation rates were collected. A quality assessment for each article was performed according to the Methodological Index for Nonrandomized Studies criteria. Results: A total of 13 studies of fair to good quality were included for analysis (one of level II evidence, five of level III, and seven of level IV) with the majority originating from the United States [n = 8, 61.5%]. Overall, there were a total of 3381 cases (1861 RTSA and 1520 ATSA), with a mean patient age of 72.6 years [range: 45-92 years]. From the studies analyzed in this systematic review, for RTSA, the approximate average number of cases surgeons need to perform to move to an acceptable position on the RTSA learning curve is 25 cases. For ATSA, a wider range of 16-86 cases was derived as only two studies reported on ATSA. Conclusion: Progression along the learning curve for RTSA and ATSA results in decreased operative times, improved patient-reported outcomes, and fewer complications. However, a true learning curve is difficult to quantify given the heterogeneity of reported outcome measures, individual surgeon experience at the time of data collection, and statistical analyses used across studies.

The pathogenesis of primary glenohumeral arthritis (GHOA) is mediated by a complex interaction between osseous anatomy and the surrounding soft tissues. Recently, there has been growing interest in characterizing the association between the anterior shoulder joint capsule and primary GHOA because of the potential for targeted treatment interventions. Emerging evidence has shown substantial synovitis, fibrosis, and mixed inflammatory cell infiltrate in the anterior capsule of osteoarthritic shoulders. In addition, increased thickening of the anterior shoulder joint capsule has been associated with greater posterior glenoid wear and humeral head subluxation. While these findings suggest that anterior capsular disease may play a causative role in the etiology and progression of eccentric GHOA, further studies are needed to support this association. The purpose of this article is to review the pathogenesis of primary GHOA, contextualize current hypotheses regarding the role of the anterior capsule in the disease process, and provide directions for future research.

Background: It is critical for orthopedic surgery residents and residency programs to have a current understanding of the content and resources utilized by the Orthopedic In-Training Examination (OITE) to continuously guide study and educational efforts. This study presents an updated analysis of the shoulder and elbow section of the OITE. Methods: All OITE questions, answers, and references from 2013 to 2019 were reviewed. The number of shoulder and elbow questions per year was recorded, and questions were analyzed for topic, imaging modalities, cognitive taxonomy, and references. We compared our data to the results of a previous study that analyzed shoulder and elbow OITE questions from 2002 to 2007 to examine trends and changes in this domain overtime. Results: There were 177 shoulder and elbow questions (126 shoulder, 71.2%; 51 elbow, 28.8%) of 1863 OITE questions (9.5%) over a 7-year period. The most commonly tested topics included degenerative joint disease/stiffness/arthroplasty (31.6%), anatomy/biomechanics (16.9%), instability/athletic injury (15.3%), trauma (14.7%), and rotator cuff (13.6%). Half of all questions involved clinical management decisions (49.7%). A total of 417 references were cited from 56 different sources, the most common of which were the Journal of Shoulder and Elbow Surgery (23.3%), Journal of the American Academy of Orthopaedic Surgeons (20.4%), and Journal of Bone and Joint Surgery (American Volume) (16%). The average time lag from article publication to OITE reference was 7.7 years. Compared with a prior analysis from 2002 to 2007, there was a significant increase in the number of shoulder and elbow questions on the OITE (5.5% to 9.5%; P < .001). Recent exams incorporated more complex multistep treatment questions (4.4% vs. 49.7%; P < .001) and fewer recall questions (42.2% vs. 22%; P < .001). There was a significant increase in the use of imaging modalities (53.3% vs. 79.1%; P < .001). No significant differences in the distribution of question topics were found. Conclusions: The percentage of shoulder and elbow questions on the OITE has nearly doubled over the past decade with greater emphasis on critical thinking (eg, clinical management decisions) over recall of facts. These findings should prompt educators to direct didactic efforts (eg, morning conferences and journal club) toward case-based learning to foster critical thinking and clinical reasoning skills.

Background:. Orthopaedic surgery remains one of the most competitive residency specialties, with the number of applicants outpacing the availability of residency positions each year. The purpose of this study was to analyze present-day orthopaedic surgery match data, identify differences between matched and unmatched applicants, and compare our findings to previous trends. Methods:. Applicant data from the National Resident Matching Program from 2016 to 2022 were analyzed. The number of matched and unmatched US allopathic senior orthopaedic applicants relative to the number of available positions was used to determine respective match rates. Performance metrics and applicant characteristics were compared by match status. Trends were compared with those of previous analysis from 2006 to 2014. Results:. The number of applicants increased from 863 in 2016 to 1,068 in 2022. The match rate decreased from 75% in 2016 to 66% in 2022 (p < 0.0001). Matched applicants had a higher number of contiguous ranks (12.3 vs. 6.5; p < 0.001), United States Medical Licensing Examination (USMLE) Step-1 score (248 vs. 240; p < 0.001), USMLE Step-2 score (255 vs. 247; p < 0.001), Alpha Omega Alpha (AOA) membership (38% vs. 13%; p < 0.001), and enrollment at a top 40 National Institutes of Health (NIH)-funded medical school (34% vs. 24%, p < 0.001). Compared with 2006 to 2014 data, a smaller percentage of matched applicants were enrolled in a top 40 NIH-funded medical school (34% vs. 37%, p = 0.013). The mean differences in USMLE Step-1 score (16 vs. 8.25 points, p < 0.001) and USMLE Step-2 score (16 vs. 8.25 points, p = 0.002) in favor of matched applicants nearly halved compared with that in 2006 to 2014. In addition, there was no longer a significant difference in the number of research products (abstracts, presentations, posters, and publications) between matched and unmatched applicants (p = 0.309). Conclusions:. Differences in the academic attributes of matched and unmatched orthopaedic surgery applicants have become less profound over time, making it increasingly difficult to predict a successful match based on USMLE Step scores, AOA membership, research productivity, and medical school research reputation. Future studies should evaluate differences in subjective metrics (e.g., away rotation and interview performance and letters of recommendation) by match status.