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Durable humeral component fixation in shoulder arthroplasty is important to prevent loosening. Humeral component designs include metaphyseal fitting, diaphyseal fitting with traditional stem length, short stem, and stemless designs. Stem geometry helps resist rotational and axial stress. Stem collars may prevent subsidence, and may be smooth for full cementation or textured proximally for bone ingrowth. Ideally, the humeral component has solid initial fixation, durable long-term fixation, minimizes humeral stress shielding, has low intra-operative complication rates, and can easily be revised. Excellent outcomes can be achieved, but there remain relative indications and contraindications for cementing or press-fitting the humeral component.

Anatomic total shoulder arthroplasty has been the gold standard for glenohumeral osteoarthritis without rotator cuff tear. There is a subset of patients with severe glenoid bone loss and glenoid retroversion that have predictably worse outcomes with component loosing and posterior instability, making reverse shoulder arthroplasty an attractive solution. Although reverse shoulder arthroplasty solves many issues with glenoid component loosing, it has concerns of higher complication rates and reduced functional outcomes. With a deeper understanding of biomechanics, there are several strategies including augmented glenoid components to make anatomic total shoulder arthroplasty a more viable option for severe glenoid bone loss.

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Given its extra-articular location, the MCL has great healing capacity such that the mainstay of treatment for most injuries remains conservative management. However, certain injury patterns place patients and athletes at risk of residual valgus laxity, which may require delayed surgical care and prolonged time out from sports. As such, identifying the specific injuries known to place patients at risk for failure with nonoperative management is of paramount importance. Although controversy remains regarding the optimal treatment of grade III MCL injuries, it is generally accepted that MCL ruptures from the distal tibia attachment require operative fixation. This technique article with accompanying video provides a detailed description of a technique for repairing the distal MCL attachment with suture augmentation. There are several advantages associated with an augmented direct repair including early, safe rehabilitation; prevention of valgus instability; and avoiding the comorbidities associated with a larger reconstruction.

Objectives: Resilience, which is a psychometric property related to “hardiness” or the ability to respond to challenging situations, is a recognized predictor in many outcomes’ domains. This has been studied extensively in stressful situations such as military returning from deployment, serious disease, and traumatic injury. To date however, no study has assessed the role of patient resiliency with respect to surgical outcome. The purpose of this study was to assess the role of preoperative resiliency as calculated by the Brief Resiliency Score (BRS) on relevant surgical outcomes, including the time required to return to full unrestricted activity following an arthroscopic Bankart repair. In addition the correlation between pre-operative BRS with post-operative BRS, post-operative Western Ontario Instability Index (WOSI), American Shoulder and Elbow (ASES) and Single Assessment Numeric Evaluation (SANE) scores was also assessed. Methods: This is a retrospective review of prospectively gathered data on 25 consecutive active duty military patients undergoing an arthroscopic Bankart repair for instability. The mean follow-up was 24.3 months (range, 23-27) as the primary outcome was return to unrestricted duty which occurs within the first year post-intervention. There were 24 males and 1 female. All patients were on unrestricted active military duty prior to injuring the operative shoulder. All patients completed BRS, WOSI, ASES, and SANE questionnaires prior to operative intervention. They then completed the same questionnaires at the most recent follow-up as well as an additional questionnaire on military duty status (unrestricted duty, limited duty, medical separation from the military). Patients were divided into low resiliency and high resiliency groups based on a score of Results: All patients had been cleared for return to full-duty or were undergoing a medical separation at final follow-up. There were no differences between groups in demographics, glenoid bone loss, or glenoid track status. Pre-operative BRS was significantly correlated with time to return to full duty, need for medical separation from the military, post-operative WOSI, SANE and ASES scores and change between pre- and post-operative WOSI, ASES and SANE scores. Those patients with high resiliency returned to full duty significantly faster than the low resiliency group (4.4 v 6.7 months, pConclusion: Preoperative resiliency was highly predictive of the time required to return to full, unrestricted military duty. It was also predictive of post-operative subjective and objective outcomes as well as overall improvement between pre- and post-operative outcomes scores. Highly resilient patients were able to return to duty 2 months faster with significantly fewer requiring medical separation from the military than those lacking resiliency.

Background: Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis. Methods: This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males. Results: Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions ( t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25). Conclusions: Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis. Level of Evidence: Level IV, prognostic case series.

Background: Femoroacetabular impingement is a common cause of hip pain in young adults. Several preoperative risk factors for poor outcomes with surgery have been identified; however, to our knowledge, no study has attempted to determine the effect of psychiatric comorbidity on outcomes with femoroacetabular impingement surgery. Methods: A retrospective review was performed on active-duty patients at one institution undergoing surgery for femoroacetabular impingement over five years. Medical records were reviewed for demographic characteristics, radiographic data, and history of mental health medication use. Return-to-duty status was considered the primary outcome measure. Outcome scores obtained included modified Harris hip scores, Single Assessment Numeric Evaluation scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, patient satisfaction, and Veterans RAND-12 scores. Patients taking mental health medication were compared with those who were not with regard to return to duty and validated patient-reported outcome measures. Results: Ninety-three patients (mean age, 32.2 years) were available for follow-up at a mean duration of 3.6 years. Of the seventeen patients discharged from service postoperatively, twelve (71%) were taking mental health medications. One-third (twenty-five) of seventy-six patients who returned to duty were taking mental health medication and this difference was significant (p < 0.006). Patients taking mental health medication had significantly poorer modified Harris hip scores (p < 0.02), WOMAC scores (p < 0.0008), and Veterans RAND-12 mental scores (p < 0.001). Antidepressant, antipsychotic, and multiple mental health medication use were all predictive of medical discharge due to hip pain. Conclusions: Psychiatric comorbidities are an important risk factor in active-duty military personnel undergoing surgery for femoroacetabular impingement. Mental health medication use is associated with poorer outcome scores and can significantly lower the possibility of returning to active-duty status. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the “critical” cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, “subcritical” amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability. Purpose: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable. Results: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences ( P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure ( P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile’s increasing bone loss predictive of a worse functional outcome. Conclusion: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that “critical” bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.

Objectives: Anterior labroligamentous periosteal sleeve avulsion lesions (ALPSA) have been identified as a potential risk factor for failure of an arthroscopic labral repair. The objective of this study was to compare the failure rates and clinical outcomes of arthroscopic ALPSA repair to arthroscopic Bankart repair. Additionally, the role of glenoid bone loss on failure rates was analyzed within each group. Methods: This was a retrospective review of 72 consecutive patients with anterior shoulder instability (73 shoulders) who underwent an anterior arthroscopic labral repair at a single military institution by one of three Sports medicine fellowship trained orthopaedic surgeons. At the time of surgery, a diagnostic arthroscopy identified 13 (17.8%) ALPSA lesions and 60 (82.2%) isolated Bankart lesions. All lesions were repaired and placed on standard post-operative protocol. Data was collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, SANE score, and recurrence rates. Failure was defined as recurrent dislocation. Additionally, glenoid bone loss in all patients was calculated using a standardized technique on preoperative images. Outcomes were analyzed by type of initial lesion. The effect of bone loss on failure rate was analyzed between and within groups. Results: The average age at surgery was 26.3 years (range, 20-42) with an average follow-up of 53.3 months (range, 28-63). There were 13 distinct ALPSA lesions and 60 Bankart lesions identified on diagnostic arthroscopy. There were no significant differences between groups with respect to any demographic data. There was 1 failure (7.7%) in the ALSPA group and 8 failures (13.3%) in the Bankart group (p=0.10). There was no significant difference between groups for WOSI or SANE scores. There was no significant difference in glenoid bone loss between groups. The ALPSA group had 13.1% glenoid bone loss compared to 13.5% in the Bankart group (p=0.88). Conclusion: Contrary to previously published data, we did not find patients with ALPSA lesions to be at an increased risk for failure of an arthroscopic repair compared to an isolated Bankart repair, nor was there a difference in functional outcomes between groups. Finally, the presence of an ALPSA lesion was not predictive on increased glenoid bone loss in this population.

Objectives: While bone loss is increasingly recognized as a risk factor for failure after arthroscopic stabilization, the precise definition of critical bone loss has not been defined. Additionally, there is no clarity on the amount of bone loss routinely present in patients presenting for primary arthroscopic stabilization of anterior glenohumeral instability. The purpose of this study is to report on the average bone loss measured in primary isolated Bankart reconstructions of the shoulder and to determine what amount of bone loss correlated to a recurrence of instability. Methods: This is a retrospective review of a consecutive series of 94 anterior instability patients (97 shoulders) who underwent arthroscopic labral repair at a single military institution by one of three fellowship trained orthopaedic surgeons. Data was collected on demographics and rate of redislocation as reported by the patient at the most recent follow-up. Glenoid bone loss was calculated from preoperative imagining using a “perfect-circle” technique. Patients were excluded if they had previously undergone any stabilization procedure. Results: The average age at surgery was 25.6 years (range, 16-42) with average follow-up of 36.8 months (range, 20-57). There were 5 females (5 shoulders) and 89 males (92 shoulders). The average bone loss in all patients was 14.4% (range, 0-34.7%). When analyzed based on the presence or absence of recurrence, there were 77 stable shoulders with no redislocations. In this group, the average bone loss was 14.5% (range, 0-33.3%) with a follow-up of 36.3 months (range, 20-57). There were 20 patients with recurrent dislocations who had an average of 20.8% (range, 0-33.3%) with a 39.1 month (range, 21-56) follow-up. There was a significantly greater amount of bone loss in those with redislocations (p=0.004). When further analyzed, there was a 95% likelihood of redislocation with 17.1% bone loss there was a 25% likelihood of redislocation with 7.0% bone loss. Conclusion: This study suggests that glenoid bone loss is a common finding in patients undergoing primary arthroscopic stabilization. Additionally, patients with “subcritical” bone loss of 17.1% are at a higher risk to have a recurrence than those with lesser amounts of bone loss. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures.

Objective The purpose of this study was to describe the epidemiology and demographics of surgically treated shoulder instability stratified by direction. We hypothesized that there would be an increased frequency of posterior and combined shoulder instability in our population compared with published literature. Secondarily, we assessed preoperative magnetic resonance imaging (MRI) reports to determine how accurately they detected the pathology addressed at surgery. Materials and methods A retrospective review was conducted at a single facility during a 46-month period. The study included all patients who underwent an operative intervention for shoulder instability. The instability in each case was characterized as isolated anterior, isolated posterior, or combined, according to pathologic findings confirmed at arthroscopy. The findings were retrospectively compared with official MRI reports to determine the accuracy of MRI in characterizing the clinically and operatively confirmed diagnosis. Results A consecutive series of 231 patients (221 men, 10 women) underwent stabilization for shoulder instability over 46 months. Patients were a mean age of 26.0 years. There were 132 patients (57.1%) with isolated anterior instability, 56 (24.2%) with isolated posterior instability, and 43 (18.6%) with combined instability. Overall, MRI findings completely characterized the clinical diagnosis and arthroscopic pathology in 149 of 219 patients (68.0%). Conclusion The rate of posterior and combined instability in an active population is more common than has been previously reported, making up more than 40% of operatively treated instability, including a previously unreported incidence of 19% for combined instabilities. In addition, MRI was often incomplete or inaccurate in detecting the pathology eventually treated at surgery.

Human hepatitis B virus is a risk factor for the development of hepatocellular carcinoma. The hepatitis B virus x protein (HBx) has been shown to inactivate the p53 tumor suppressor protein and impair DNA repair, cell cycle, and apoptosis mechanisms. Herein we report that HBx represses two components of the transcription-repair factor TFIIH, XPB (p89), and XPD (p80), both in p53-proficient and p53-deficient liver cells. This inhibition is observed while HBx maintains its transactivation function. Expression of HBx in liver cells results in down-regulation of endogenous XPB and XPD mRNAs and proteins; this inhibition is not observed with other TFIIH subunits, XPA or PCNA. In liver tissue from HBx transgenics, XPB and XPD proteins are down-regulated in comparison to matched normal liver tissue. HBx has been shown to interact with Sp1 transcription factor and affects its DNA binding activity. Sp1 is essential for the basal promoter activity of XPB in liver cells and Drosophila SL2 cells. In the Sp1-deficient SL2 cells, HBx-induced XPB and XPD inhibition is Sp1-dependent. In summary, our results provide evidence that HBx represses the expression of key TFIIH proteins at least in part through Sp1 elements; this repression may impair TFIIH function in DNA repair mechanisms.

Flexor tendon entrapment after a pediatric forearm fracture is a rarely reported complication that is often diagnosed late. Flexor tendon entrapment is more frequently reported after distal forearm fractures, and possible etiologies include fibrosis secondary to hemorrhage at the fracture site and simple entrapment of the muscle belly. This article describes a case of ring finger flexor digitorum profundus entrapment in a 12-year-old boy with a closed both-bone forearm fracture that was treated with closed reduction and intramedullary nail fixation. Preoperatively, the patient had full flexion and extension of all fingers. The entrapment was noted at the first postoperative follow-up when the patient could fully extend the ring finger proximal interphalangeal joint but was unable to concomitantly extend the metacarpal phalangeal joint. Magnetic resonance imaging and ultrasound were obtained to identify the entrapment site. Intraoperatively, a portion of the flexor digitorum profundus musculotendinous junction was entrapped in the fracture site. After release of the entrapment, the patient gained immediate passive range of motion. Subsequently, the hardware was removed, and the patient healed and regained full ring finger function. To the authors’ knowledge, this is the only report of isolated ring finger flexor digitorum profundus entrapment after closed reduction and intramedullary fixation of a pediatric forearm fracture. The authors recommend vigilant physical examination of passive and active range of motion of all digital joints with the wrist in flexion and extension before and after bony manipulation.

Elbow arthrodesis can be used for complex elbow injuries that are complicated or fail other conventional treatment methods. We present a case report of an anterior ulnohumeral compressive plate elbow arthrodesis for a patient with a complex elbow injury from a gunshot wound that failed initial open reduction and internal fixation and posterior ulnohumeral arthrodesis secondary to numerous complications.

The progression of primary tumors to an invasive phenotype requires dynamic changes in multiple cellular and local tumor microenvironment markers. In this study, we report a genomic approach to assess gene transcriptional changes upon overexpression of ErbB receptors, in vitro and in vivo, focusing on markers involved in the regulation of the tumor microenvironment. ErbB receptors (ErbB-1/epidermal growth factor receptor, ErbB-2, ErbB-3, and ErbB-4) were stably overexpressed in a polyclonal cell population as single or paired combinations using murine and human breast cell models. The overall numbers of known genes that are up- or down-regulated was significantly higher in cells and tumors overexpressing paired combinations of receptors compared with cells and tumors overexpressing single ErbB receptors. Genes encoding components of cell-cell structures, extracellular matrix, coagulation factors, and angiogenesis were predominantly affected by the most active ErbB receptor combinations and were predictive of the aggressive in vivo tumorigenicity, a feature that was not always seen in vitro. Among ErbB-regulated tumor microenvironment markers detected by the genomic analysis, thrombospondin 1, an endogenous inhibitor of angiogenesis, was additionally validated in relation to tumor growth phenotype. Thrombospondin 1 mRNA and protein were down-regulated by specific ErbB receptors, in vitro and in both rodent and human ErbB-induced tumors, consistent with the extent of tumor growth and tumor vascularization associated with specific ErbB receptors. In summary, our genomic results highlight the broad diversity of ErbB-regulated cancer-associated genes and revealed several novel targets that may have potential therapeutic applications for targeting tumor progression involving aberrations of ErbB receptors.