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Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%;10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

Background Revisions of apparently "aseptic" shoulder arthroplasties are not infrequently culture positive for Propionibacterium , organisms that may be introduced at the time of the index surgery when the dermal sebaceous glands are transected. This report seeks to answer the question, Do surgeons performing revision shoulder arthroplasty years after the index procedure need to be concerned about the persistence of Propionibacterium ? Methods We reviewed the medical records of 148 revision arthroplasties performed between July 2008 and June 2013 to find those revisions performed at least 3 years after the index procedure and at which intraoperative cultures were strongly positive for Propionibacterium . Results We identified 14 cases of revision surgery performed 8 ± 4 years after the original arthroplasty for which deep cultures were strongly positive for Propionibacterium. A total of 109 specimens were obtained, 84 of which were positive. All 14 patients were male. Conclusion Shoulder arthroplasties revised for the mechanical problems of loosening or stiffness can be substantially culture positive for Propionibacterium , even if the revision is performed many years after the index procedure. Therefore, even in shoulder arthroplasties revised for mechanical problems years after the index procedures, surgeons should consider submitting multiple deep specimens for specific Propionibacterium culture. In the presence of persistent Propionibacterium , surgeons should consider the need for directed surgical and medical treatment in their management of a failed arthroplasty.

Background:Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.Purpose:To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.Study Design:Systematic review and meta-analysis of articles with evidence levels 1-4.Methods:A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.Results:While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. The inconsistent and incomplete data in the published articles limited the meta-analysis of factors affecting the outcome of rotator cuff repair.Conclusion:In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient. To accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patient’s condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function.

Purpose To compare the torsional stability of 6 fixation techniques for intercarpal fixation including a 4-tine, in-line staple. Methods We chose the scapholunate interval as the test site for rotational stability for various constructs. We used 42 pairs of embalmed scaphoids and lunates for the comparisons and created 6 construct groups. Fixation of the scapholunate gap was performed with a 3-mm screw, 2 1.1-mm (0.045-inch) K-wires spaced 2 mm apart, or 2 1.1-mm K-wires spaced 5 mm apart. One member of each pair was fixed with either a standard 2-tine peripherally placed staple or a customized 4-tine staple. Each scapholunate construct was tested in torsion to failure on a biaxial materials testing machine. Results In all cases, the 4-tine staple significantly increased rotational stability. The 2-tine staple resulted in statistically insignificant increases in rotational stability. With central fixation alone, K-wires separated by 5 mm showed the greatest resistance to torsion, and the 3-mm screw showed the least. Conclusions Use of an in-line, 4-tine staple provided increased rotational stability and may result in enhanced healing of intercarpal ligamentous reconstructions and arthrodeses. Clinical relevance A 4-tine staple compared with a standard staple provided superior rotational stability for intercarpal fixation.

Objective: To determine if the type of health insurance is associated with a delay in children obtaining orthoses. Methods: The medical records of 60 children who were prescribed an ankle-foot orthosis (AFO) or thoracolumbosacral orthosis (TLSO) were retrospectively reviewed. Ten children were randomly chosen with either of 3 types of insurance (government, health maintenance organizations [HMOs], and preferred provider organizations [PPOs]) with an orthosis provided by a single supplier. The time interval between prescription and insurance company authorization was recorded, as well as the interval between prescription and procurement of the orthosis. Results: There were significant differences in the time from prescription to authorization of orthoses between insurance types (P = 0.001) and time from authorization until brace procurement between insurance types (P = 0.01). Children with PPO insurance received authorization for an AFO faster than children with government insurance or an HMO (P < 0.05). Children with government insurance received authorization for a TLSO significantly later than children with PPO insurance (P = 0.004) or HMO insurance (P = 0.03). The difference in time between authorization and procurement of a TLSO in children with PPO insurance (36 days) was strikingly different from that of children with government insurance (123 days) (P = 0.003). Discussion: This study documents that children with government insurance face delays in obtaining orthotic treatment compared with children with PPO insurance. The delay in the procurement of the more expensive brace (TLSO is approximately 4 times the cost of an AFO) correlated to more striking delays in the government-insured population.