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Background: Revision reverse total shoulder arthroplasty (rTSA) of a previously cemented humeral component is challenging. In hip arthroplasty, the cement-within-cement (CwC) technique has been well described as an effective option. However, for shoulder arthroplasty there remains a paucity of data investigating this technique. The purpose of this study was to determine the mid-term outcomes of patients who underwent a revision rTSA utilizing the CwC for management of the humeral component. Methods: Between 2005 and 2021, 68 revision rTSA using the CwC technique with a minimum of 2 years clinical follow-up were identified from a single institution joint registry database. Revised implants consisted of 38 (55.9%) hemiarthroplasties, 22 (32.4%) anatomic total shoulder arthroplasties, and 8 (11.8%) rTSA. A total of 12 (17.6%) shoulders required an osteotomy (corticotomy or window) to assist with extraction of the cemented stem. The mean follow-up after revision was 5.4 years (range, 2-16 years). Surgical complications, reoperations, revisions, and implant survivorship were assessed. Results: Of the 12 shoulders that required an osteotomy for component removal, 11 (91.7%) were healed. At final follow-up, the overall complication rate was 26.9%. The most common complication was fracture or fragmentation of the greater tuberosity (20.6%, n = 13) with 10 (76.9%) cases showing signs of healing at final follow-up. The overall survivorship free of revision surgery was 88.2% at 2 and 80.9% at 5 years, respectively. The most frequent causes of re-revision surgery were aseptic glenoid component loosening (n = 4) and instability (n = 4), with only 2 (2.9%) patients developing humeral component loosening (at 2 and 5 years, respectively). Male sex was associated with an increased risk of revision surgery (hazard ratio [HR], 3.52 [95% confidence interval [CI] 1.22-10.18]; P = .02) and complications (HR, 3.56 [95% CI, 1.40-9.07]; P = .008). The grade of postoperative lucent lines at the humerus (HR, 1.35 [95% CI, 1.04-1.74]; P = .02) and glenoid (HR, 1.59 [95% CI, 1.22-2.10]; P = .001) also correlated with an increased risk of re-revision surgery. Conclusion: The CwC technique is a reliable option for revising previously cemented humeral components in revision rTSA. Although a low rate of humeral component loosening was observed, higher rates of complications and re-revision surgery were observed over time secondary to aseptic glenoid component loosening and instability, which are not directly related to CwC technique but to revision surgery in general.

Background: Paralysis of the trapezius muscle most commonly results from iatrogenic injury to the spinal accessory nerve. Methods: The clinical presentation and physical examination findings of trapezius palsy have been well characterized, but unfortunately the diagnosis of this condition is oftentimes missed or delayed, sometimes leading to unnecessary surgery on the rotator cuff or tendon of the long head of the biceps. Results: The diagnosis can be confirmed using electromyography with nerve conduction studies. Although nonoperative treatment may help some patients with temporary neurapraxia of the spinal accessory nerve, nerve repair with or without nerve grafting should be performed soon for patients suspected of a nerve transection. Nerve transfers can be considered within the first year after the injury when nerve repair and grafting cannot be completed. For chronic trapezius palsy, transfer of the levator scapulae and rhomboids has been refined and represents a very successful surgical procedure. Rarely, scapulothoracic arthrodesis is considered for individuals with failed tendon transfers or multiple nerve involvement. Conclusion: Trapezius palsy is oftentimes missed. An accurate diagnosis allows consideration of various treatment modalities that have been reported to provide good outcomes for properly selected patients.

Introduction:. International medical graduates (IMGs) continue to play an important role in the US health care system, but little is known about their trends of matching into highly competitive residencies such as orthopedic surgery. The purpose of this study was to analyze temporal trends of IMG applicants matching into US orthopedic residency programs between 2008 and 2024 and compare them with US allopathic (MD) and osteopathic (DO) graduates. Methods:. Orthopedic residency specific data for years 2008 to 2024 was obtained from the National Resident Match Program and Electronic Residency Application Service. Variables collected included total number of programs, total positions offered, number of applicants (MD, DO, and IMG), positions filled, and fill rate for each group. Trends were examined using simple linear regression modeling. Results:. The number of orthopedic residency programs increased from 160 (2008) to 218 (2024), with total positions increasing from 636 (2008) to 916 (2024). The IMG fill rate decreased from 2.99% in 2008 to 0.87% in 2024 (p < 0.01 for linear trend; β −0.069). This corresponds to an absolute number decrease of 19 IMGs in 2008 to 8 in 2024. More specifically, the proportion of US IMGs decreased from 0.94% to 0.66%, and the proportion of non-US IMGs decreased from 2.04% to 0.21%. Over the 17-year study period, a total of 105 US IMGs and 110 non-US IMGs matched into orthopedic surgery. The US MD applicant fill rate decreased significantly from 96.5% to 85.0% (p < 0.001; β −0.944). The DO applicant fill rate increased significantly from 0.31% to 13.97% (p < 0.0001; β 0.990). Conclusion:. The declining rate of IMGs matching into orthopedic residency programs in the United States underscores the growing challenges faced by IMGs in accessing training in this competitive specialty. The notable increase in DO graduates securing orthopedic residency positions likely reflects the integration of a unified accreditation system for MD and DO residency programs established in 2020. Level of Evidence:. Retrospective Cohort Study; IV

Background: Artificial intelligence (AI) is a continuously expanding field with the potential to transform a variety of industries—including health care—by providing automation, efficiency, precision, accuracy, and decision-making support for simple and complex tasks. Basic knowledge of the key features as well as limitations of AI is paramount to understand current developments in this field and to successfully apply them to shoulder surgery. The purpose of the present review is to provide an overview of AI within orthopedics and shoulder surgery exploring current and forthcoming AI applications. Methods: PubMed and Scopus databases were searched to provide a narrative review of the most relevant literature on AI applications in shoulder surgery. Results: Despite the enormous clinical and research potential of AI, orthopedic surgery has been a relatively late adopter of AI technologies. Image evaluation, surgical planning, aiding decision-making, and facilitating patient evaluations over time are some of the current areas of development with enormous opportunities to improve surgical practice, research, and education. Furthermore, the advancement of AI-driven strategies has the potential to create a more efficient medical system that may reduce the overall cost of delivering and implementing quality health care for patients with shoulder pathology. Conclusion: AI is an expanding field with the potential for broad clinical and research applications in orthopedic surgery. Many challenges still need to be addressed to fully leverage the potential of AI to clinical practice and research such as privacy issues, data ownership, and external validation of the proposed models.

Background: Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs. Methods: A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported. Results: Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%. Conclusions: Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.

Purpose: To compare the cost-effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum. Methods: A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results: Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness-to-pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost-effective strategy in 69% of patients included in the microsimulation model. Conclusions: Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost-effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold. Level of Evidence: Level III, economic computer simulation model.

Background: Medial-sided elbow injuries are becoming increasingly common among throwing athletes due to overuse and increased specialization at early ages. High valgus stress and repetitive elbow flexion/extension during throwing not only affects the ligaments and dynamic support of the elbow, but commonly affects the ulnar nerve. Indications: Management of cubital tunnel syndrome is initially rest, therapy, and functional training; however, if conservative measures do not appropriately address the ulnar neuropathy, surgical decompression with subcutaneous transposition is a reliable treatment option. Technique Description: An incision is created over the medial epicondyle. The medial antebrachial cutaneous nerve is identified and protected. The ulnar nerve is identified and tagged with a vessel loop to allow for appropriate handling of the nerve. Decompression of the ulnar nerve begins proximally by spreading the tissues superficial to the ulnar nerve and splitting the fascia overlying it. Then, dissection deep to the nerve is performed. A small strip of the medial intermuscular septum will be used as a sling to hold the nerve securely in the transposed position. This is released proximally and the distal attachment to the medial epicondyle is left in place. Decompression is then continued distally by releasing the superficial fascia over the flexor carpi ulnaris (FCU) and a portion of the deep FCU muscle belly and fascia. The nerve is decompressed circumferentially, while preserving penetrating branches to the FCU as able. Ultimately, the ulnar nerve is decompressed 10 cm proximal and 10 cm distal to the medial epicondyle. The intermuscular septum is then pulled over the nerve, checked for appropriate length, and sutured in place both posterior and anterior to the ulnar nerve. Results: Symptom improvement after decompression and transposition is high (>90%); however, performance outcomes in overhead and throwing athletes is variable, and return to previous or higher level of play ranges from 60% to 90%. Discussion/Conclusion: Ulnar nerve decompression and transposition can reliably address underlying symptoms, but results are mixed for return to sport outcomes in overhead and throwing athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae. Methods: Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk. Results: The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P

AimsAs has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).MethodsExperimental knees were immobilized for either four weeks (72 mice) or eight weeks (72 mice), followed by a remobilization period of zero weeks (24 mice), two weeks (24 mice), or four weeks (24 mice) after suture removal. Half of the experimental knees also received an intra-articular injury. Biomechanical data were collected to measure passive extension angle (PEA). Histological data measuring area and thickness of posterior and anterior knee capsules were collected from knee sections.ResultsExperimental knees immobilized for four weeks demonstrated mean PEAs of 141°, 72°, and 79° after zero, two, and four weeks of remobilization (n = 6 per group), respectively. Experimental knees demonstrated reduced PEAs after two weeks (p < 0.001) and four weeks (p < 0.0001) of remobilization compared to controls. Following eight weeks of immobilization, experimental knees exhibited mean PEAs of 82°, 73°, and 72° after zero, two, and four weeks of remobilization, respectively. Histological analysis demonstrated no cartilage degeneration. Similar trends in biomechanical and histological properties were observed when intra-articular violation was introduced.ConclusionThis study established a novel mouse model of robust knee contracture without evidence of OA. This was appreciated consistently after eight weeks of immobilization and was irrespective of length of remobilization. As such, this arthrofibrotic model provides opportunities to investigate molecular pathways and therapeutic strategies.Cite this article: Bone Joint Res 2023;12(1):58–71.

Background: We aimed to evaluate midterm patient-reported outcomes and reoperation rates following rotator cuff repair in patients with either rheumatoid arthritis (RA) or other inflammatory arthritis (nonRA-IA) diagnoses. Methods: We identified all patients with either RA or nonRA-IA who underwent a rotator cuff repair at our institution between 2008 and 2018. IA diagnoses included RA, systemic lupus erythematosus, psoriatic arthritis, and other unspecified inflammatory arthritis. We compiled a cohort of 51 shoulders, with an average follow-up time of 7.0 years. The average age was 60 years (range 39-81), and 55% of patients were female. Patients were contacted via phone to obtain patient-reported outcomes surveys. Univariate linear regression was used to evaluate associations between patient characteristics and outcomes. Results: A review of preoperative radiographs demonstrated that 50% of patients presented with some degree of glenohumeral joint inflammatory degeneration. At the final follow-up, the mean visual analog score for pain was 2 (range 0-8), and the mean American Shoulder and Elbow Surgeons score (ASES) was 77 (standard deviation [SD] = 19). The mean subjective shoulder value was 75% (SD = 22%), and the average satisfaction was 9 (SD 1.9). The mean Patient-Reported Outcomes Measurement Information System upper extremity score was 41 (SD = 10.6). Female sex and a complete tear (vs. partial) were both associated with lower ASES scores, whereas no other characteristics were associated with postoperative ASES scores. The 5-year Kaplan-Meier survival estimate free of reoperation was 91.8% (95% confidence interval 83.0-99.8). Conclusions: Rotator cuff repair in patients with RA or other inflammatory arthritis diagnoses resulted in satisfactory patient-reported outcomes that seem comparable to rotator cuff repair when performed in the general population. Furthermore, reoperations were rare, with a 5-year survival rate free of reoperation for any reason of over 90%. Altogether, an inflammatory arthritis diagnosis should not preclude by itself attempted rotator cuff repair surgery in these patients.

Background: Total health care spending in the United States is increasing. In order to improve our delivery of high-quality, patient-centric, and cost-effective care, artificial intelligence (AI) and its subsets are being increasingly explored and utilized in medicine. Applications of AI in orthopedic surgery, including shoulder and elbow surgery, are being actively studied and have stirred much discussion. However, the trends of research on AI applications in shoulder and elbow surgery have not yet been quantified. Thus, the purpose of this study is to explore the general trends of research in applying AI to shoulder and elbow surgery and to examine characteristics of these research publications. Methods: A literature search was conducted using PubMed for all articles published between January 1, 2000 and May 12, 2022. The primary search query used was as follows: (shoulder) and (AI OR machine learning OR deep learning OR neural networks). Exclusion criteria were as follows: (1) not pertinent to orthopedic surgeons (2) not pertaining to shoulder or elbow surgery, and (3) not pertaining to AI, machine learning, and deep learning. Selected articles in high-impact and relevant orthopedic journals were further characterized and analyzed. Results: The annual number of articles increased from 1 article in 2006 to 24 articles in 2021. There was a 4-fold increase in publications between 2019 and 2021, and a 6-fold increase between 2018 and 2021. The average number of publications per year increased exponentially from 2010 to 2021 (R2 = 0.608; P = .003). The three journals with the most publications were Journal of Shoulder and Elbow Surgery (12), followed by Arthroscopy (2), and Clinical Orthopaedics and Related Research (2). Conclusion: This study provides quantitative evidence for the first time that publications applying AI and its subsets to shoulder and elbow surgery are growing exponentially since the year 2010, with the most rapid growth beginning between the years of 2019 and 2020.

Abstract Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating condition typically diagnosed based on clinical findings. To gain insight into the histopathologic immune cell microenvironment of arthrofibrosis, we assessed the extent of tissue fibrosis and quantified immune cell populations in specific tissue regions of the posterior capsule. We investigated specimens from three prospectively-collected, matched cohorts, grouped as patients receiving a primary TKA for osteoarthritis, revision TKA for arthrofibrosis, and revision TKA for non-arthrofibrotic, non-infectious reasons. Specimens were evaluated using hematoxylin and eosin staining, picrosirius red staining, immunofluorescence, and immunohistochemistry with Aperio®-based digital image analysis. Increased collagen deposition and increased number of α-SMA/ACTA2 expressing myofibroblasts were present in the arthrofibrosis group compared to the two non-arthrofibrotic groups. CD163 + macrophages were the most abundant immune cell type in any capsular sample with specific enrichment in the synovial tissue. CD163 + macrophages were significantly decreased in the fibrotic tissue region of arthrofibrosis patients compared to the patients with primary TKA, and significantly increased in adipose tissue region of arthrofibrotic specimens compared to non-arthrofibrotic specimens. Synovial CD117 + mast cells were significantly decreased in arthrofibrotic adipose tissue. Together, these findings inform diagnostic and targeted therapeutic strategies by providing insight into the underlying pathogenetic mechanisms of arthrofibrosis.

Background: Venous thromboembolic events (VTEs) following orthopedic surgery may lead to serious morbidity and mortality. Fortunately, VTEs following upper extremity procedures are uncommon. However, the true incidence is likely underreported. The aim of this study is to provide a systematic review, excluding large database studies, to report on the incidence of VTEs following shoulder arthroscopic procedures. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review of multiple databases was performed. A comprehensive search of several databases from inception to September 1, 2021, limited to English language and excluding animal studies, was designed and conducted. Studies were screened by 2 independent reviewers. A decision to exclude studies from large surgical or insurance claim databases was made to minimize the risk of including overlapping data points in this systematic review. Results: Thirteen studies met inclusion and exclusion criteria and form part of this systematic review. A total of 32,407 patients were included in this study. Among these patients, the deep vein thrombosis, pulmonary embolism, and overall VTE rates were 0.15%, 0.08%, and 0.21%, respectively. Among the patients specified to have undergone arthroscopic rotator cuff repair, the rate of deep vein thrombosis, pulmonary embolism, and overall VTE was 0.71%, 0.37%, and 1.04%, respectively. Conclusion: While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. Factors such as operative time, open procedures, obesity, and altitude may increase the risk of postoperative VTE although conflicting data exist. Current literature supports the idea that chemical antithrombotic prophylaxis likely provides no significant advantage over early mobilization in reducing VTEs following shoulder arthroscopy in low-risk patients.

Despite the development of various therapeutic options, surgical management of irreparable rotator cuff tears (IRCTs) remains controversial. Recently, implantation of a biodegradable subacromial balloon spacer (InSpace, Stryker Corporation; Kalamazoo, MI) has gained considerable interest for the treatment of certain IRCTs. The reported outcome of balloon implantation has not been consistent, likely due to differing indications and technical approaches. The purpose of this article is to present a reproducible arthroscopic technique for implantation of a subacromial balloon and to review the literature published to date, regarding the efficacy and outcomes of this procedure.

Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty.

Background: Several bone morphological parameters, including the anterior acromion morphology, the lateral acromial angle, the coracohumeral interval, the glenoid inclination, the acromion index (AI), and the shoulder critical angle (CSA), have been proposed to impact the development of rotator cuff tears and glenohumeral osteoarthritis. This study aimed to develop a deep learning tool to automate the measurement of CSA and AI on anteroposterior shoulder radiographs. Methods: We used MURA Dataset v1.1, which is a large publicly available musculoskeletal radiograph dataset from the Stanford University School of Medicine. All normal shoulder anteroposterior radiographs were extracted and annotated by an experienced orthopedic surgeon. The annotated images were divided into train (1004), validation (174), and test (93) sets. We use pytorch_segmentation_models for U-Net implementation and PyTorch framework for training the model. The test set was used for final evaluation of the model. Results: The mean absolute error for CSA and AI between human-performed and machine-performed measurements on the test set with 93 images was 1.68° (95% CI 1.406°-1.979°) and 0.03 (95% CI 0.02 - 0.03), respectively. Conclusions: A deep learning model can precisely and accurately measure CSA and AI in shoulder anteroposterior radiographs. A tool of this nature makes large-scale research projects feasible and holds promise as a clinical application if integrated with a radiology software program.

Background: Osteochondritis dissecans (OCD) of the capitellum can be a disabling condition that typically affects adolescent, overhead athletes. To date, a variety of different surgical treatment options have been described. Indications: Surgical indications for osteochondral allograft transplantation (OCA) for capitellar OCD lesions include failure of nonsurgical management or prior surgery and unstable, full-thickness lesions of almost any size affecting both bone and cartilage. The anconeus preserving approach specifically provides wide access to nearly the entire capitellum and can be used for lesions in almost any location. Technique Description: The anconeus preserving approach for OCA utilizes the interval between the anconeus and the ulna. With the patient positioned supine and the elbow flexed on an arm table, an incision is made approximately 1 cm lateral to the olecranon and is carried down to the fascia. Electric cautery is used to dissect the interval between the ulna and the anconeus. The anconeus is elevated off the ulna and retracted laterally to expose the underlying joint capsule. An L-shaped capsulotomy is performed over the center of the capitellum, just proximal to the annular ligament of the radial head. A pin is placed into the center of the lesion, perpendicular to the capitellum. A cannulated reamer 0.5 mm smaller than the lesion is used to ream the lesion to a depth of approximately 5 mm. Depth measurements are taken at all 4 poles of the defect. About 3 cc of bone marrow aspirate harvest is then obtained from the ulna using a cannulated needle. The oscillating saw is used to cut the graft to size using the prior measurements. The bone marrow aspirate is placed onto the osseous side of the graft before the osteochondral graft is impacted into the recipient site. The capsulotomy is then closed, and the anconeus is repaired back to the ulna. Postoperatively, patients begin range of motion as soon as tolerated, initiate strengthening at 6 weeks, and initiate return-to-sport programming at 3 months. Results: Lesions treated with OCA typically demonstrate improvement in all outcome measures, including functional scores, graft incorporation, articular surface congruity, and return-to-sport. Complications and graft failure is rare. Discussion/Conclusion: OCA using an anconeus preserving approach is a reliable option for surgical management of unstable OCD lesions. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Aseptic loosening, polyethylene wear, and mechanical failure have limited the use of total elbow arthroplasty (TEA) in physically demanding patients. Newer implant designs have been introduced to improve mechanical performance. The purpose of this study was to report the results obtained after implantation of the Nexel TEA. Methods: Over a 3-year period, 2 surgeons implanted a total of 35 consecutive Nexel primary TEAs. The average patient age was 65 years, and standard TEA indications were utilized. Elbows were evaluated for pain, motion, the Mayo Elbow Performance Score, complications, and reoperations. Results: Twelve elbows underwent a revision surgery with removal of either a part of or all Nexel components at an average of 2.2 years. All revision surgeries performed at our institution revealed gross loosening of the component(s). Metallic debris and periprosthetic fractures were present in 45% and 50% of cases, respectively. Radiographic evaluation of existing components revealed humeral component loosening and periprosthetic fractures in 2 and 4 elbows, respectively. Overall, 17 of 35 (50%) elbows underwent reoperation, and 20 of 35 (60%) elbows sustained at least 1 postoperative complication. Conclusion: Primary TEA with implantation of this implant was associated with an unacceptably high rate of early implant loosening, periprosthetic fracture, and reoperation. We hypothesize that this early unexpected mechanical failure could be explained by both the utilization of a titanium-on-polyethylene bearing surface and a more posterior center of rotation causing premature anterior impingement with flexion leading to failure of the bonding interface, secondary titanium particle shedding, polyethylene wear, and osteolysis.

Background: While the effect of clopidogrel on outcomes in elective hip and knee arthroplasty has been well described, there is a paucity of data regarding elective shoulder arthroplasty. Methods: Fifty-eight patients were identified who underwent primary anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty while prescribed clopidogrel. There were 33 (57%) reverse shoulder arthroplasties and 25 (43%) TSAs performed. Patients were separated into two groups based upon their use of clopidogrel in the preoperative period. Twenty patients (35%; group 1) continued clopidogrel through surgery, and 38 patients (65%; group 2) did not. The mean age was 74 years, and the mean follow-up was 42 months. Results: Both groups demonstrated substantial improvements in pain and motion: visual analog scale pain improved by 7 points (P

Background: Parkinson’s disease (PD) is a neurodegenerative disorder associated with inferior clinical outcomes after surgical management of many orthopedic conditions. The purpose of this systematic review was to define the clinical, functional, and patient-reported outcomes of shoulder arthroplasty (SA) in patients with PD. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was completed using the Ovid platform for searches in MEDLINE, EMBASE, Cochrane Central, and Cochrane Systematic Reviews, with additional searches in Web of Science and Scopus. Included studies were full-length, English-language, clinical investigations reporting on SA in patients with PD with at least one clinical outcome. Results: Seven studies including 7126 patients (7134 SA) met inclusion criteria with a mean age of 72.6 (range, 69.5–75.8 years), 58.9% female, and the average follow-up duration was 65 months (range, 17–119 months). Anatomic total shoulder arthroplasty (aTSA) was the most reported implant surgery (n = 3455, 48.4%) followed by hemiarthroplasty (HA) (n = 2840, 39.8%), and reverse shoulder arthroplasty (RSA) (n = 839,1.8%). SA consistently improved pain. Forward elevation, abduction, and external rotation had a pooled mean increase of 36°, 20°, and 6°, respectively. Complications occurred at a pooled rate of 22.5%, with stiffness (7.1%), need for revision (5.3%), and instability (4.7%) as the most common complications reported. Reoperations inclusive of revisions occurred at a lower pooled rate of 5.6%, with aTSA (n = 201; 9.0%) having the highest rate, followed by HA (n = 158; 7.1%), and then RSA (n = 42; 1.9%). Conclusions: The results of the present systematic review demonstrate that SA in patients with PD results in consistent pain relief. However, inferior improvements in clinical outcomes may be expected when compared with patients without PD, likely due to the neurodegenerative manifestations of this disorder. In addition, RSA had a lower reoperation rate than HA and aTSA in patients with PD.

Aims: Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release. Methods: A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks. Results: IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)). Conclusion: IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value. Cite this article: Bone Joint Res 2022;11(1):32–39.

Abstract Background Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). Methods This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes. Results Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p

Hypothesis/Background: Value-based healthcare delivery models are becoming increasingly common and are driving cost effectiveness initiatives. Rotator cuff repair (RCR) is a commonly performed procedure with some variations on the specific surgical technique. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 categories of RCR techniques (open [oRCR], combined arthroscopically assisted and mini-open [CRCR], and all arthroscopic [ARCR]) at a high-volume institution. Methods: All RCR procedures performed by 2 fellowship-trained shoulder surgeons at a single institution between 2012 and 2017 were retrospectively identified. These consisted of oRCR, CRCR, and ARCR repair techniques. One surgeon performed oRCR and CRCR, and the second surgeon performed ARCR. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. Results: The cohort consisted of 95 oRCR, 233 CRCR, and 287 ARCR. Median standardized costs were as follows: preoperative evaluation $486.03; index surgical hospitalization oRCR $9,343.10, CRCR $10,057.20, and ARCR $10,330.60; and postoperative care $875.02. Preoperative and postoperative costs did not vary based on the type of RCR performed. However, significant differences were observed among index surgical costs (P = .0008). The highest standardized cost for hospitalization for both the CRCR group and the ARCR group was related to the cost of the operating room and the implants. The 90-day complication, reoperation, and readmission rates were 1.1%, 1.1%, and 2.1% in the open group; 0.8%, 0.8%, and 1.7% in the combination group; 0%, 0%, and 1.7% in the all arthroscopic group, respectively. There were no significant differences among the 3 surgical procedures with respect to complication (P = .26), reoperation (P = .26), and readmission rates (P = .96). Discussion/Conclusions: In this investigation, the median standardized costs for RCR inclusive of 60-day workup and 90-day postoperative care were $10,704.15, $11,418.25, and $11,691.65 for oRCR, CRCR (average added cost $714.10), and ARCR (added cost $987.50), respectively. The group complication, reoperation, and readmission rate were 0.5%, 0.5%, and 1.8% with no significant differences between the varying techniques, respectively. This retrospective cost analysis and complication profile may serve as a useful reference as surgeons consider engaging in bundled payment for RCR. As value based initiatives continue to progress, implant cost may serve as an actionable area for cost reduction.

Background: Glenoid baseplate and glenosphere positioning may affect scapular notching rates. The purpose of this study was to assess various radiographic parameters and correlate them with scapular notching after primary reverse total shoulder arthroplasty (RTSA) at a minimum follow-up time of 5 years. Methods: The study sample included 147 primary RTSA with good-quality postoperative radiographs at least 5 years after implantation (mean follow-up 6.1 years, range 5-12 years). The center of rotation (COR) of the glenosphere in reference to the bone-baseplate interface was medialized in 71 and lateralized in 76 shoulders, with a varus polyethylene opening angle in 134 shoulders. Preoperative and immediate postoperative radiographs were measured to determine (1) glenoid baseplate inclination: α, β, and the reverse shoulder arthroplasty (RSA) angles; (2) glenoid component inferiorization—peg glenoid rim distance (PGRD); and (3) sphere bone overhang distance (SBOD). Scapular notching was graded according to the Sirveaux classification. Results: Scapular notching was noted in 98 shoulders (67%) and classified as grade 1 in 46, grade 2 in 25, grade 3 in 20, and grade 4 in 7. There were statistically significant associations between notching and both medialized glenospheres (91% vs. 45%, P = .001) and varus polyethylene angle (P = .0001). The mean postoperative RSA angle, PGRD, and SBOD were 6.6 degrees, 23.8 mm, and +2.6 mm, respectively. Preoperative α and postoperative β, RSA, PGRD, and SBOD were all associated with notching (P < .05). The rate of reoperation was 2.7% at a minimum of 5 years, with reasons for reoperation related to component failure in only one shoulder. Conclusion: Scapular notching correlates with glenoid and baseplate inclination, baseplate inferiorization, inferior glenosphere overhang, glenosphere COR, humeral polyethylene angle, and longer clinical follow-up. SBOD is a clinically useful measurement with decreased values associated with notching. It is the superior measurement in implants with eccentric glenospheres. Moderate or severe notching was seen in only approximately 15% of the shoulders. Revision surgery was extremely low in this cohort, and it was not related to notching or instability.

Background:. Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality. Methods:. Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups. Results:. The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality. Conclusions:. Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract Purpose The term “pectoralis minor syndrome” refers to this constellation of symptoms that can occur when the pectoralis minor (Pm) is shortened and contracted. Release of the tendon of the Pm from the coracoid has been reported to provide substantial clinical improvement to patients presenting with pectoralis minor syndrome. The purpose of this study was (1) to describe the technique for endoscopic release of pectoralis minor tendon at the subdeltoid space, (2) to classify the pectoralis minor syndrome according to its severity and (3) and to report the short‐term outcomes of this procedure in a consecutive series of patients diagnosed with pectoralis minor syndrome. Methods Endoscopic release of the pectoralis minor tendon was performed in a series of 10 patients presenting with pectoralis minor syndrome. There were six females and four males with a median age at the time of surgery of 42 (range from 20 to 58) years. Four shoulders were categorized as grade I (scapular dyskinesis), and six as grade II (intermittent brachial plexopathy). Shoulders were evaluated for pain, motion, satisfaction, subjective shoulder value (SSV), quick‐DASH, ASES score, and complications. The mean follow‐up time was 19 (range, 6 to 49) months. Results Arthroscopic release of the tendon of the Pm led to substantial resolution of pectoralis minor syndrome symptoms in all but one shoulder, which was considered a failure. Preoperatively, the median VAS for pain was 8.5 (range, 7–10) and the mean SSV was 20% (range, 10% ‐ 50%). At most recent follow‐up the mean VAS for pain was 1 (range, 0–6) and the mean SSV 80% (range, 50% ‐ 90%). Before surgery, mean ASES and quick‐DASH scores were 19.1 (range, 10–41.6) and 83.1 (range, 71 and 95.5) points respectively. At most recent follow‐up, mean ASES and quick‐DASH scores were 80.1 (range, 40–100) and 19.3 (range, 2.3–68) points respectively. No surgical complications occurred in any of the shoulder included in this study. Conclusions Endoscopic release of the tendon of the pectoralis minor from the coracoid improves pain, function and patient reported outcomes in the majority of patients presenting with the diagnosis of isolated pectoralis minor syndrome.

Purpose: To generate an evidence-based opioid-prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture. Methods: Data collected from a randomized controlled trial that compared continuous passive motion (CPM) (n = 24) to physical therapy (PT) (n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty-one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use. Results: The median total opioid prescription was 437.5-mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5-mg oxycodone). Twenty-two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age

The purpose of the present cross-sectional study was to analyze the relationship between adherence to healthy lifestyles and academic performance in students of different Vocational Education and Training (VET) degrees. Methods: 55 Vocational Education students´ from the Animation and Physical-Sports Activities Course (n 28) and from Dental Pathology and the Prosthetic Anatomy courses (DPPA) (n 27), were analyzed through the G-PAQ and the KIDMED questionnaires, to asess their adherence to Physical Activity and to Mediterranean diet. In addition, anthropometric dataand academic qualifications were correlated. Results: APSA students scored significantly higher in Mediterranean diet adherence, as well as in the number of minutes of vigorous and moderate intensity aerobic exercise. DPPA students obtained significantly higher values in sedentary activities. No significant differences were found in the academic performance of both groups. Conclusion: the practice of PA was positively correlated with a greater adherence to Mediterranean diet. This fact entails a factor of prevention of cardiovascular and metabolic disease in the future. Thus, the implementation of nutritional education and PA programs for VET students is suggested. Resumen. El objetivo del presente estudio fue analizar la relación entre la adherencia a estilos de vida saludables y el rendimiento académico en estudiantes de diferentes titulaciones de Formación Profesional (FP). Método: 55 estudiantes del curso de Animación y Actividades Físico-Deportivas (TAFAD) (n 28) y de los cursos de Patología Dental y Anatomía Protésica (DPPA) (n 27), fueron analizados a través de los cuestionarios G-PAQ y KIDMED, para valorar su adherencia a la Actividad Física y a la dieta mediterránea. Además, se correlacionaron datos antropométricos y calificaciones académicas. Resultados: Los estudiantes de TAFAD obtuvieron puntuaciones significativamente más altas en la adherencia a la dieta mediterránea, así como en la cantidad de minutos de ejercicio aeróbico vigoroso y de intensidad moderada. Los alumnos de la DPPA obtuvieron valores significativamente más altos en actividades sedentarias; no se encontraron diferencias significativas en el rendimiento académico de ambos grupos. Conclusión: la práctica de AF se correlacionó positivamente con una mayor adherencia a la dieta mediterránea. Este hecho conlleva un factor de prevención de enfermedades cardiovasculares y metabólicas en el futuro. Por tanto, se sugiere la implementación de programas de educación nutricional y AF para estudiantes de FP.

Background:. Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States. Methods:. The National Inpatient Sample (NIS) was queried to count all patients who underwent total shoulder arthroplasty (TSA), including both anatomic and reverse TSA, and hemiarthroplasty between 1988 and 2017. The counting method was used to calculate the current prevalence of TSA and hemiarthroplasty using age and sex-specific population and mortality data from the U.S. Census Bureau. Results:. In 2017, an estimated 823,361 patients (95% confidence interval [CI], 809,267 to 837,129 patients) were living in the United States with a shoulder replacement. This represents a prevalence of 0.258%, increasing markedly from 1995 (0.031%) and 2005 (0.083%). Female patients had a higher prevalence at 0.294% than male patients at 0.221%. Over 2% of people who were ≥80 years of age in the United States were living with a shoulder replacement. Furthermore, approximately 60% of patients living with a shoulder replacement had undergone the operation between 2013 and 2017. The incidence of revision shoulder arthroplasty is increasing on an annual basis, with 10,290 revision procedures performed in 2017, costing the U.S. health-care system $205 million. Conclusions:. The prevalence of shoulder arthroplasty in the United States has markedly increased over time. This trend will likely continue given increasing life expectancies and exponentially increasing shoulder arthroplasty incidence rates. Most patients do not have long-term follow-up, and revision shoulder arthroplasty rates are increasing, a trend that is projected to continue. The data from our study highlight the enormous public health impact of shoulder replacement and shed light on a potentially increasing revision burden.

Purpose: To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD). Methods: A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded. Results: Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations. Conclusions: Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects. Level of Evidence: Level IV, systematic review of studies, all Level IV evidence.

Innate immune cellular effectors are actively consumed during systemic inflammation, but the systemic traffic and the mechanisms that support their replenishment remain unknown. Here, we demonstrate that acute systemic inflammation induces the emergent activation of a previously unrecognized system of rapid migration of granulocyte-macrophage progenitors and committed macrophage-dendritic progenitors, but not other progenitors or stem cells, from bone marrow (BM) to regional lymphatic capillaries. The progenitor traffic to the systemic lymphatic circulation is mediated by Ccl19/Ccr7 and is NF-κB independent, Traf6/IκB-kinase/SNAP23 activation dependent, and is responsible for the secretion of pre-stored Ccl19 by a subpopulation of CD205+/CD172a+ conventional dendritic cells type 2 and upregulation of BM myeloid progenitor Ccr7 signaling. Mature myeloid Traf6 signaling is anti-inflammatory and necessary for lymph node myeloid cell development. This report unveils the existence and the mechanistic basis of a very early direct traffic of myeloid progenitors from BM to lymphatics during inflammation.

Abstract Purpose The teres minor is particularly important for activities that require external rotation in abduction in the settings of both rotator cuff tears and reverse shoulder arthroplasty. This study sought to assess the incidence of teres minor fatty infiltration in a large cohort of consecutive patients evaluated with shoulder MRI for shoulder pain and to identify all associated pathologies in an effort to determine the various potential etiologies of teres minor involvement. Methods A retrospective review of 7,376 non‐contrast shoulder MRI studies performed between 2010 and 2015 were specifically evaluated for teres minor fatty infiltration. Studies were reviewed by two fellowship trained musculoskeletal radiologists. Muscle atrophy was graded on a 3‐point scale according to Fuchs and Gerber. The remaining rotator cuff tendons and muscles, biceps tendon, labrum, and joint surfaces were assessed on MRI as well. Results In this series, 209 (2.8%) shoulders were noted to have fatty infiltration of the teres minor. The rate of isolated fatty infiltration of the teres minor was 0.4%. Concomitant deltoid muscle atrophy was common, and occurred in 68% of the shoulders with fatty infiltration of the teres minor. Tearing of the teres minor tendon was extremely rare. Conclusion Fatty infiltration of the teres minor can occur in isolation, be associated with deltoid muscle atrophy only, or occur in the setting of rotator cuff full tears. Thus, fatty infiltration of the teres minor may be related to a neurologic process or disuse. Further long term longitudinal studies are necessary to be elucidate the etiologies. Level of Evidence Level IV.

Abstract The elbow is particularly prone to stiffness. Loss of elbow motion is very limiting, and can be the result of trauma, primary osteoarthritis, heterotopic ossification and other conditions. Several exposures have been described for open elbow contracture release. Although a few decades ago elbow arthroscopy was considered only for diagnosis and removal of loose bodies, contemporary arthroscopic techniques allow successful management of the majority of conditions leading to elbow stiffness. Careful patient evaluation, use of advanced imaging studies, and acquisition of appropriate surgical skills are essential for the successful arthroscopic management of the stiff elbow. This expert opinion reviews some fundamentals of elbow stiffness as well as principles for the evaluation and arthroscopic management of the stiff elbow.

Studies on demand impact for 9-ending and rounded prices have so far offered controversial results, with hardly any research focusing on their effect on online commerce or in a multichannel sales context. Our study aims to fill this gap by analyzing the conditions that influence the strategy behind setting such type of pricing in the multichannel retail business of fast-moving consumer goods (FMCG). To test the formulated hypotheses, scanner data from FMCG retailers are used. In addition to “demand” and “price”, “promotion communication”, “retailer type” and “price level” are included as moderators between 9-ending, rounded prices and demand. The results aim to provide, both in the academic and business fields, systematic findings of pricing relationships between online and offline channels which contribute to a better management strategy for “9-ending” and “rounded” prices. Keywords: Prices; 9-ending Prices; Rounded Prices; E-Commerce. JEL Classifications: M31, L81, C32 DOI: https://doi.org/10.32479/irmm.10683

Although anterior shoulder instability is most commonly treated with arthroscopic fixation, open labral repair with capsular shift may be best for select patients and in cases of revision stabilization without significant bone loss. The technique described in this article uses the deltopectoral interval; it involves careful dissection of the subscapularis from the anterior capsule, repair of the Bankart lesion, and a lateral and superior capsular shift using all-suture anchors in the humeral head. Advantages of this technique include meticulous control of anchor placement and the ability to provide additional stability via a lateral and superiorly directed capsular shift. This operation can be performed in a reliable, efficient, and reproducible manner.

In the machine learning literature we can find numerous methods to solve classification problems. We propose two new performance measures to analyze such methods. These measures are defined by using the concept of proportional reduction of classification error with respect to three benchmark classifiers, the random and two intuitive classifiers which are based on how a non-expert person could realize classification simply by applying a frequentist approach. We show that these three simple methods are closely related to different aspects of the entropy of the dataset. Therefore, these measures account somewhat for entropy in the dataset when evaluating the performance of classifiers. This allows us to measure the improvement in the classification results compared to simple methods, and at the same time how entropy affects classification capacity. To illustrate how these new performance measures can be used to analyze classifiers taking into account the entropy of the dataset, we carry out an intensive experiment in which we use the well-known J48 algorithm, and a UCI repository dataset on which we have previously selected a subset of the most relevant attributes. Then we carry out an extensive experiment in which we consider four heuristic classifiers, and 11 datasets.

Background Substantial proximal humeral bone loss may compromise reverse shoulder arthroplasty secondary to limited implant support, insufficient soft tissue tension due to shortening, lack of attachment sites for the posterosuperior cuff when present, and lack of lateral offset of the deltoid. In these circumstances, use of a proximal humeral replacement may be considered. Patients/Methods Between 2012 and 2014, 34 consecutive reverse shoulder arthroplasties were performed using a proximal humeral replacement system. The indications were failed shoulder arthroplasty (15), oncology reconstruction (9), humeral malunion/nonunion (7), prior resection arthroplasty (2), and intraoperative fracture (1). All patients were included in the survival analysis. Twenty-two patients with minimum 2-year follow-up were included in analysis of clinical results. Results Among the cohort of 34 patients, there were 8 additional reoperations: humeral loosening (3), periprosthetic fracture (2), irrigation and debridement (2), and glenoid loosening (1). Humeral component loosening occurred exclusively in patients undergoing revision shoulder arthroplasty. The 4 patients had an average 3.75 prior procedures before the proximal humeral replacement. Two of the revisions were from cemented to uncemented stems. Among the 23 patients with minimum 2-year follow-up, there was significant improvement in pain scores (4.1 vs 0.6), forward elevation (31 vs 109) degrees, and 81% were satisfied. Conclusion Use of a proximal humeral replacement when performing a reverse shoulder arthroplasty in the complex setting of substantial proximal humerus bone loss provides good clinical results and a particularly low dislocation rate. However, the rate of loosening of the humeral component in the revision setting suggests that proximal humeral replacement components should be cemented when revising a previously cemented stem. IRB 16-006966.

Introduction Primary reverse shoulder arthroplasty has been reported to provide good outcomes. The majority of designs utilize a large portion of the glenoid. Some studies have reported worrisome rates of notching and stress fractures of the acromion or scapular spine. The purpose of this study was to determine the outcome and complications of a bone-preserving reverse prosthesis with limited ingrowth glenoid surface paired with an onlay humeral component. Materials and methods Between 2014 and 2015, 96 reverse arthroplasties were implanted using a bone-preserving reverse with a 135° onlay humeral bearing. Six patients died. The remaining 87 patients (90 shoulders) were followed for 2 years or until revision. Mean age was 69.3 years. The underlying diagnosis was cuff tear arthropathy (13), irreparable cuff tear (39), osteoarthritis (32), and other (6). Shoulders were followed for 2 years or until revision surgery. Results Reverse shoulder arthroplasty resulted in significant improvements in pain, motion, and function. At most recent follow-up, 74 shoulders had no or mild pain. Elevation was 131° ± 31° and external rotation 46° ± 21°. The mean American Shoulder and Elbow Surgeons (ASES) score was 76. There were 4 reoperations for deep infection (2), periprosthetic fracture, and glenoid loosening. None of the remaining arthroplasties were loose. There was one stress fracture of the acromion and one of the spine of the scapula. No radiographic notching or dislocation was observed. Discussion Primary reverse arthroplasty using a bone-preserving glenoid component and an anatomic onlay humeral bearing provides satisfactory clinical outcomes with a very low rate of failure and complications.

Background: High rates of radiographic loosening have been reported with various glenoid designs. Many available designs sacrifice most of the bone at the central portion of the glenoid vault, creating large areas of deficiency when revision becomes necessary. The purpose of this study was to report the 2- to 5-year outcome of shoulder arthroplasty using a bone-preserving all-polyethylene glenoid components with self-pressurizing pegs. Methods: Between August 2011 and December 2014, 202 consecutive anatomic total shoulder arthroplasties (TSAs) were performed by a single surgeon with implantation of a self-pressurizing cemented pegged glenoid component in 190 patients (12 patients had both shoulders replaced). Patients were followed up prospectively and evaluated for pain, motion, strength, American Shoulder and Elbow Surgeons (ASES) scores, and radiographic changes. The mean follow-up time was 2.7 (2–5) years. Results: TSA improved pain and function reliably. At the most recent follow-up, 94% of the shoulders had no or mild pain. Motion included 154 ± 25° of elevation, 68 ± 18° of external rotation, and median internal rotation to T10 (range, iliac crest to T4). The most recent average ASES score was 82 ± 15 points. Early postoperative radiographs showed no radiolucent lines. No humeral or glenoid component was considered radiographically loose at the most recent follow-up. Complications requiring reoperation included subscapularis insufficiency (4), posterior instability (2), deep infection (1), stiffness (1), and a painful loose body (1). No components were revised for loosening. Conclusions: Anatomic TSA using a cemented bone-preserving all-polyethylene pegged self-pressurizing glenoid component provided satisfactory clinical outcomes and survival at 2 to 5 years.

Tenotomy of the subscapularis is commonly used for exposure at the time of anatomic total shoulder arthroplasty. Understanding the anatomy of the subscapularis and its footprint for insertion into the lesser tuberosity helps perform an adequate tenotomy. Incision of the tendon at the right level, release of the anterior capsule to restore excursion, a sound repair, and postoperative protection are important. Controversy remains regarding the relative advantages and disadvantages of tenotomy compared with alternatives, in particular osteotomy of the lesser tuberosity. Tenotomy has been associated with a higher rate of positive physical examination findings for subscapularis weakness and concerning tendon attenuation or rupture in some shoulders evaluated with ultrasound. However, patient-reported outcomes, objective measurement of strength in internal rotation, and revision and reoperation rates are identical with tenotomy and osteotomy. Tenotomy is particularly attractive in terms of simplicity, shorter operative time, and use in stemless shoulder arthroplasty. Failure of the tenotomy to heal leading to anterior instability can be salvaged surgically, but oftentimes requires revision to a reverse arthroplasty.

Reconstruction of the lateral ulnar collateral ligament of the elbow is the primary treatment for recurrent symptomatic posterolateral rotatory instability. Although a number of lateral ulnar collateral ligament reconstruction techniques have been described, the docking technique has received general acceptance. In this technique, the graft is passed through a tunnel on the ulnar side and the 2 free limbs are docked into the humerus at the isometric point on the lateral condyle. Advantages of this method of reconstruction include reduced bone removal, decreased soft tissue damage, and precise control of graft tensioning. When precise surgical steps are followed, this technique can be performed in a reliable, efficient, and reproducible manner for patients with posterolateral rotatory instability of the elbow.

Background Proper soft tissue balance is paramount to maintaining stability and a functional arc of motion in shoulder arthroplasty but is impaired in patients with prior glenohumeral (GH) dislocations. The purpose of this study was to determine the clinical outcomes, revisions, and complications of reverse shoulder arthroplasty (RSA) in patients with a history of glenohumeral dislocation. Methods Twenty-four patients with a history of GH dislocations that developed arthropathy underwent primary RSA from 2007 to 2013 were retrospectively reviewed. Mean follow-up was 3.3 years (2–7 years). Mean age was 70 years. Eight patients (33%) and 7 patients (29%) had complete or partial subscapularis deficiency, respectively. Results Twenty-two patients (92%) had little to no pain at final follow-up. Mean shoulder elevation improved from 48° to 120° ( P

Background Dislocation is a challenging complication after reverse shoulder arthroplasty (RSA). We sought to evaluate the outcome of nonoperative and operative management of the dislocation after primary and revision RSA. Methods Between 2006 and 2013, dislocation occurred in 12/1081 primary RSAs (1.1%) and 15/342 revision RSAs (4.4%). Seventeen (69%) shoulders dislocated within 3 months of surgery. Ten (68%) patients underwent revision RSA for prosthetic instability. Mean age was 69 years, and mean follow-up after index RSA was 4 years. Results Closed reduction and bracing achieved a stable shoulder in 60% (3/5 patients) after primary and 20% (1/5 patients) after revision RSA dislocation. Operative management achieved a stable shoulder in 88% (7/8 patients) of primary and 64% (7/11 patients) of revision RSAs ( P = .40). Overall, 9 shoulders (33%) had persistent instability at the final follow-up: 2/12 (17%) primaries versus 7/15 (47%) revisions ( P = .08). Preoperative prosthetic instability was the main risk factor for chronic instability in the revision cohort ( P = .02). Worse functional outcomes were associated with the dislocation of a revision RSA ( P = .02). Conclusion After primary RSA dislocations, closed reduction is successful in half, while revision surgery is successful in 85% of cases. Conversely, closed reduction of a dislocated revision RSA is rarely successful, while revision surgery is successful 65% of the time. Every attempt should be made to achieve stability at the time of primary and revision RSA, since reduction or revision surgery does not guarantee the restoring stability.

In recent years, arthroscopy has gained popularity as a preferred treatment of a multitude of pathologies affecting the elbow. Since its initial description in 1985, many modifications have been made as our knowledge and technology have advanced. Currently, the majority of arthroscopic procedures are performed in either the lateral decubitus or supine suspended position. In this work, we discuss the history, patient positioning, and key steps for performing elbow arthroscopy in the lateral decubitus position. In addition to key steps, a number of strengths and limitations of this set up are discussed in detail. When properly executed, elbow arthroscopy can be performed in a safe and efficient manner with minimal risk to patients.