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Glenoid exposure for total shoulder replacement can be challenging and represents the most difficult part of the procedure. Exposure requires both humeral and glenoid-based releases. We prefer a lesser tuberosity osteotomy instead of a subscapularis takedown. The osteotomy offers significant advantages for glenoid visualization by decreasing the encroachment of anterior humeral bone. Specific glenoid-based releases are then performed in this sequential fashion: 1) the rotator interval including the coracohumeral and superior glenohumeral ligament is released, 2) the middle glenohumeral ligament is divided in an inferior direction, 3) the inferior glenohumeral ligament is then divided as the inferior extension of the above dissection, and 4) posterior glenoid retractors are placed and the axillary nerve is directly visualized. An inferior capsular release then is performed dependent on the necessity of further exposure.

Infection of shoulder arthroplasties is a relatively rare (0.5%) but potentially devastating complication. Treatment includes resection arthroplasty, debridement and prosthetic retention, immediate exchange arthroplasty, and staged-exchange arthroplasty. To date, the most reliable treatment is staged-exchange arthroplasty. Debridement and prosthetic retention can be considered with infections detected within 3 weeks of onset, well-fixed components, no signs of osteomyelitis, and if the infecting organism is not staph epidermidis. Staged-exchange arthroplasty involves complete removal of all components, and placement of an anatomic antibiotic-impregnated cement spacer. Results can still be quite good for pain relief after reimplantation. Functional outcome has been variable in the past but may be improved significantly with the use of the reverse implant.

The U.S. Navy is considering the installation of telemedicine equipment on more than 300 ships. Besides improving the quality of care, benefits would arise from avoiding medical evacuations (MEDEVACs) and returning patients to work more quickly. Because telemedicine has not yet been fully implemented by the Navy, we relied on projections of anticipated savings and costs, rather than actual expenditures, to determine cost-effectiveness.To determine the demand for telemedicine and the cost-effectiveness of various technologies (telephone and fax, e-mail and Internet, video teleconferencing (VTC), teleradiology, and diagnostic instruments), as well as their bandwidth requirements.A panel of Navy medical experts with telemedicine experience reviewed a representative sample of patient visits collected over a 1-year period and estimated the man-day savings and quality-of-care enhancements that might have occurred had telemedicine technologies been available. The savings from potentially avoiding MEDEVACs was estimated from a survey of ships' medical staff. These sample estimates were then projected to the medical workload of the entire fleet. Off-the-shelf telemedicine equipment prices were combined with installation, maintenance, training, and communication costs to obtain the lifecycle costs of the technology.If telemedicine were available to the fleet, ship medical staffs would initiate nearly 19, 000 consults in a year-7% of all patient visits. Telemedicine would enhance quality of care in two-thirds of these consults. Seventeen percent of the MEDEVACs would be preventable with telemedicine (representing 155,000 travel miles), with a savings of $4400 per MEDEVAC. If the ship's communication capabilities were available, e-mail and Internet and telephone and fax would be cost-effective on all ships (including small ships and submarines). Video teleconferencing would be cost-effective on large ships (aircraft carriers and amphibious) only. Teleradiology would be cost-effective on carriers only. Telemedicine's bandwidth requirement is small-1% of a month's time. However, if the ships' medical departments need to resort to a commercial satellite, E-mail and Internet would be the only telemedicine modality generating enough monetary benefits to offset the costs.

Highly cross-linked polyethylene has been associated with low in vitro wear, but also has decreased in vitro ultimate yield strength. We therefore asked whether highly cross-linked polyethylene would result in lower outcome scores, wear, or early failure in a young patient population. Seventy THAs in 64 patients were performed using a highly cross-linked (electron beam-irradiated to 9 Mrads) acetabular liner and a cobalt-chrome femoral head. The average age of the patients at surgery was 41 years (range, 19-50 years). The minimum followup was 2.4 years (average, 4 years; range, 2.4-6.5 years). We recorded demographic and clinical data, including Harris hip score. Polyethylene wear measurements were analyzed with a validated, computer-assisted, edge detection method. The average Harris hip score improved from 53 to 92 at last followup. There was no evidence of acetabular or femoral loss of fixation, subsidence, or loosening. Linear wear was undetectable at this followup interval. No patient experienced catastrophic failure or underwent revision surgery. These data show low polyethylene wear rates and no catastrophic failures at early followup in a young patient cohort.Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Athletes engaged in repetitive activity with recent increases in training or competition are at risk for stress fractures of the foot and ankle. Physical and radiographic findings are often unremarkable and diagnosis may be difficult. Although many of these injuries may be managed symptomatically, certain types of stress fractures are at higher risk for delayed union, nonunion, or refracture without aggressive immobilization or surgical fixation.