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Background As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings. Methods The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables—age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities—between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups. Results Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04). Conclusion Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

The beach chair position is commonly used when performing shoulder arthroplasty. However, this position has been associated with hypotension, potentially leading to cerebral hypoperfusion, which may cause neurologic injury. In addition, shoulder arthroplasty cases are associated with longer operative times, posing a potentially greater risk of cerebral hypoperfusion. We aim to evaluate the risk of cerebral desaturation events (CDEs) during the course of total shoulder arthroplasty.Twenty-six patients undergoing shoulder arthroplasties were monitored for changes in cerebral perfusion. Seven specific time-points during the procedure were labeled for comparison of events: baseline, beach chair, incision, humeral broaching, glenoid reaming, glenoid component implantation, and humeral component implantation. Cerebral oxygen perfusion was measured using near-infrared spectroscopy. A CDE was described as a decrease of oxygen saturation greater than 20%.Nineteeen of 25 subjects experienced a CDE. 42% of these patients experienced CDEs during semi-beach chair positioning. Patients experienced the largest oxygen saturation drop during semi-beach chair positioning. Transition from baseline to semi-beach chair was the only event to have a statistically significant decrease in cerebral perfusion (8%, P.05). There was a statistically significant percentage change in mean oxygen saturation in the semi-beach chair interval (10%, P.01) and the semi-beach chair to incision interval (7%, P.01).Most patients experienced an intraoperative CDE, with greatest incidence during semi-beach chair positioning. The largest decline in cerebral oxygen saturation occurred during semi-beach chair positioning. Implant implantation was not associated with decrease in cerebral oximetry.

» Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). » The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. » During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. » The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. » While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. » Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.

There are conflicting reports regarding the efficacy of Major League Baseball (MLB) pitchers following medial ulnar collateral ligament reconstruction (UCLR). As advanced baseball metrics have revolutionized the way general managers define pitchers' value, the authors believe that these should be used to measure clinical outcomes after UCLR. All MLB pitchers who underwent UCLR from April 1, 1991, through July 1, 2016, were compiled (N=253). Pitcher demographics and statistics were collected for up to 3 full seasons preceding and following surgery. Data for pitching controls (all MLB [AMLB] pitchers) were also collected (N=14,756). Prior to surgery, pitchers with UCLR were significantly better than the AMLB pitchers in nearly all advanced value-based statistics: higher wins above replacement (WAR; 0.93 vs 0.78; 95% confidence interval [CI], 0.80–1.06), lower fielding independent pitching (FIP; 4.23 vs 4.51; 95% CI, 4.12–4.34), lower expected fielding independent pitching (xFIP; 4.17 vs 4.38; 95% CI, 4.06–4.28), higher win probability added (WPA; 0.21 vs 0.05; 95% CI, 0.1–0.32), and higher leverage index (pLI; 1.03 vs 0.96; 95% CI, 0.99–1.06). Pitchers who returned to play after UCLR demonstrated significantly lower value with worse WAR, FIP, WPA, and pLI ( P Orthopedics . 2019; 42(6):349–354.]

Objective To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs). Background Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery. Methods Using the American Shoulder and Elbow Surgeons (ASES) directory website page “ASES-recognized Shoulder and Elbow Fellowship Programs” we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled datapoints include: age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history. Results We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. 97.5% of FLs were male while 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n=2). The top fellowship programs for producing future FLs were Mayo Clinic (n=6), Columbia University (n=6), San Francisco/California Pacific (n=4), and Washington University in St. Louis (n=4). Conclusion Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity however demographic diversity remains limited as comparable to prior orthopedic subspecialty FL investigations.

BACKGROUND: Fatty infiltration of the rotator cuff evaluated with CT has been associated with asymmetric glenoid wear and humeral head subluxation in patients with glenohumeral arthritis. The relationship between rotator cuff pathologic findings and abnormal glenoid wear plays an important role in determining the optimal surgical management of advanced glenohumeral osteoarthritis. Compared with CT, MRI has increased sensitivity for identifying rotator cuff conditions; therefore, prior studies using CT may have underestimated the association between fatty infiltration of the rotator cuff and abnormal glenoid wear. QUESTIONS/PURPOSES: (1) Compared with Type A glenoids, which muscles in which Walch subtypes have a greater degree of fatty infiltration using Goutallier scores? (2) What glenoid type is associated with greater imbalance in fatty infiltration, as measured by comparing Goutallier scores between the posterior and anterior rotator cuff muscles? (3) What is the correlation between glenoid version and fatty infiltration of the rotator cuff muscles? (4) Comparing Type B2 and B3 glenoids with Type A glenoids, after accounting for age and sex, is there an increase in fatty infiltration of the infraspinatus muscle? METHODS: A total of 129 shoulders from 129 patients undergoing anatomic total shoulder arthroplasty to treat primary glenohumeral osteoarthritis were retrospectively reviewed. Patients had an average age of 66.4 ± 9.3 years and an average BMI of 30.6 ± 6.7 kg/m(2), and 53% (69 of 129) were men. All patients underwent MRI within 12 months before total shoulder arthroplasty to assess glenoid morphology and rotator cuff pathologic findings. Three reviewers assessed the images, and glenoid morphology was assigned using the modified Walch classification system (Types A1, A2, B1, B2, B3, C, and D). Fatty infiltration of the rotator cuff was classified using Goutallier scores. The examiners demonstrated moderate-to-good reliability using these classification systems; the Walch classification system had interrater reliability kappa coefficients (κ) from 0.54 to 0.69 and intrarater reliability κ from 0.60 to 0.64. Goutallier scores using the simplified classification system had interrater reliability κ from 0.64 to 0.68 and intrarater reliability κ from 0.64 to 0.79. Thirty-six percent (46 of 129) of the shoulders had posterior wear patterns (18% [23] were Type B2 glenoids; 18% [23] were Type B3 glenoids). The average Goutallier scores for each rotator cuff muscle were determined, and the amount of fatty infiltration was compared between the various Walch subtypes using independent t-tests. Axial-plane imbalance in fatty infiltration of the rotator cuff was assessed by determining the difference in the average fatty infiltration of the posterior rotator cuff muscles (infraspinatus and teres minor) and anterior rotator cuff muscles (subscapularis) and comparing the differences among the Walch subtypes using independent t-tests. The association between glenoid version and fatty infiltration was assessed using Pearson correlations. Finally, a multivariate logistic regression model was used to assess fatty infiltration of the rotator cuff among the various Walch subtypes while accounting for patient age and sex. RESULTS: Compared with Type A1 glenoids, Type B2 and B3 glenoids had an increased amount of fatty infiltration of the infraspinatus (1.6 ± 0.7 versus 0.7 ± 0.4; mean difference 0.9 [95% CI 0.7-1.2]; p < 0.001 and 1.8 ± 0.4 versus 0.7 ± 0.4; mean difference 1.1 [95% CI 0.9-1.4]; p < 0.001, respectively) and teres minor (1.3 ± 0.7 versus 0.6 ± 0.5; mean difference 0.7 [95% CI 0.4-1.0]; p < 0.001 and 1.6 ± 0.6 versus 0.6 ± 0.5; mean difference 1.0 [95% CI 0.7-1.2]; p < 0.001, respectively). There was greater imbalance in fatty infiltration between the posterior and anterior rotator cuff muscles for Type B2 (0.5 ± 0.3) and B3 (0.6 ± 0.5) glenoids than for Type A1 (0.1 ± 0.3) and A2 (0.1 ± 0.6) glenoids (p < 0.001). Only the infraspinatus’s fatty infiltration was strongly correlated with glenoid version (r = 0.64; p < 0.001), while fatty infiltration of the other muscles only correlated weakly or moderately. After accounting for age and sex, fatty infiltration in the infraspinatus was associated with Type B2 (OR 66.1 [95% CI 7.6-577.9]; p < 0.001) and Type B3 glenoids (OR 59.5 [95% CI 5.4-661.3]; p < 0.001) compared with Type A glenoids. CONCLUSION: Compared with concentric wear, posteriorly worn glenoids had an imbalance in axial-plane rotator cuff fatty infiltration and an increased amount of fatty infiltration of the infraspinatus and teres minor compared with the subscapularis. These imbalances may contribute to the higher rates of failure after anatomic total shoulder arthroplasty in patients with posterior wear compared with those with concentric wear. Future research should be directed toward investigating the temporal relationship of these findings, as well as understanding the clinical outcomes for patients undergoing anatomic total shoulder arthroplasty who have posteriorly worn glenoids with a high degree of fatty infiltration of the posterior rotator cuff musculature. CLINICAL RELEVANCE: Providers should consider the increased likelihood of higher-grade fatty infiltration of the posterior rotator cuff in the setting of posteriorly worn glenoids, particularly when treating patients without using MRI. These patients have higher rates of failure postoperatively and may benefit from closer monitoring and altered postoperative rehabilitation protocols that target the posterior rotator cuff.

Recent evidence suggests an inhomogeneous distribution of intramuscular rotator cuff fat infiltration (FI) in a small sample of individuals with rotator cuff tears, yet clinically just a few slices at the scapular Y-view are used to evaluate FI in patients with rotator cuff tears. The purpose of this study was to determine if assessment of FI using the scapular Y-view is representative of the entire muscle in patients with full-thickness rotator cuff tears, and whether this varies by tear size.Patients (N = 25) diagnosed with full-thickness rotator cuff tear and confirmed with magnetic resonance imaging (MRI) were included. Fat-water sequences were used to objectively quantify mean FI (%) in the entire 3D muscle and the mean from 3 slices at the Y-view. Mixed-model 2 × 2 ANOVAs were used to assess for differences between methods, and if results vary by tear-size.There were no statistically significant differences between mean amount of FI of the entire 3D muscle and mean Y-view in the supraspinatus or infraspinatus muscles (p 0.05). Additionally, this did not differ across tear size groups (p 0.05).Results of this study suggest FI assessed in the Y-view is not different (mean difference 1.0%) from FI of the entire 3D muscle in patients with full-thickness rotator cuff tears. Therefore, the clinical utility of evaluating rotator cuff intramuscular fat infiltration with the Y-view is further supported in patients with full-thickness rotator cuff tears across tear sizes.

Background: Sports-related concussions have garnered significant attention in recent years because of the negative effects they can have on a player’s cognitive health and performance. In response to this growing concern, Major League Baseball (MLB) introduced a standardized concussion protocol during the 2011-2012 season. Purpose/Hypothesis: The purpose of this study was to compare the reported incidence of concussions and the subsequent performance of MLB players before and after the introduction of the standardized concussion protocol. We hypothesized that the introduction of the standardized concussion protocol would not have an impact on player performance postconcussion. Study Design: Cohort study; Level of evidence, 3. Methods: Players who suffered a concussion between 2001 and 2018 were identified from the MLB transactions page. Incidence and player performance were compared before and after the introduction of the standardized concussion protocol. Player performance was evaluated using traditional data and sabermetric data, which are advanced statistics used in conjunction with standard statistics to better compare players and teams. Player averages were calculated and compared using paired t tests for 30 days before and after concussion, 1 year before and after concussion, and career before and after concussion. Averages were also compared before and after the institution of the standardized concussion protocol using independent-measures t tests. Results: There were a total of 114 players who suffered 142 concussions, with 77% of those occurring after the introduction of the concussion protocol (32 before, 110 after). The average time missed because of concussion significantly decreased from 33.7 days (range, 10-122 days) to 18.9 days (range, 6-111 days) after the concussion protocol ( P = .0005). There was no difference in player performance (including batting average, on-base percentage, and slugging for batters; earned run average, fielding-independent pitching, and walks plus hits per inning pitched for pitchers) after concussion at any time point (30 days, 1 year, or career) when comparing these statistics before versus after the MLB concussion protocol. However, batter performance was significantly poorer 1 year after concussion and over the remainder of the players' careers ( P < .05). Conclusion: The number of reported concussions increased after the introduction of the MLB concussion protocol. However, players spent significantly less time on the disabled list without any adverse effect on player performance. Despite these changes, long-term batting performance was significantly poorer after concussion.

To determine which normalization method may best account for confounding individual factors, such as age or BMI, when quantifying fat infiltration on MRI in patients with rotator cuff tears, the effects of normalization using three different muscles (teres major; triceps brachii; teres minor) were compared. Thirty-seven consecutive patients diagnosed with rotator cuff pathology were included. MRI fat–water sequences were used to quantify rotator cuff intramuscular fat (%fat). Three reference muscles (teres major, triceps, teres minor) were used to derive normalized %fat. Relationships between intramuscular %fat and tear size, age, and BMI in each rotator cuff muscle, before and after normalization, were compared with Fisher transformations (α = 0.05). Normalization with teres major ameliorated confounding relationships of age and BMI on rotator cuff %fat. In contrast, normalization with triceps maintained the confounding relationships between %fat and age in supraspinatus (p = 0.03) and infraspinatus/teres minor (p = 0.028). Normalization with teres minor maintained the confounding relationship between %fat and BMI in subscapularis (p = 0.039). Normalization with teres major best-maintained relationships between tear size and infraspinatus/teres minor %fat (p = 0.021). In contrast, normalization with triceps or teres minor eliminated all significant relationships with tear size. Results of this pilot study suggest normalization to teres major using MRI-based %fat quantification methods can effectively control for individual factors, such as BMI or age, and may have utility in evaluating and monitoring rotator cuff fat infiltration attributed specifically to a tendon tear.

Background Previous studies have shown no correlation between adhesive capsulitis and hemoglobin A 1c (HbA 1c ). However, HbA 1c is only a measure of short-term blood sugar control. We created a previously nonvalidated variable, cumulative HbA 1c , that uses HbA 1c values over time to estimate the total disease burden a single individual experiences over a period. In this study, we aimed to evaluate whether a correlation exists between cumulative HbA 1c levels in diabetic patients and the prevalence of frozen shoulder. We hypothesized that poor long-term glucose control would be correlated with increased incidence of adhesive capsulitis. Methods A retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbA 1c values were collected. A total of 24,417 patients met the inclusion criteria. A variable was created establishing the cumulative magnitude of abnormal HbA 1c values over time, termed “cumulative HbA 1c .” Logistic regression analysis was performed to determine whether long-term glucose control was predictive of the development of adhesive capsulitis. Results Cumulative HbA 1c was positively associated with adhesive capsulitis (7.6 × 10 –5 ) (ie, odds ratio of 1.000076). The effect size of cumulative HbA 1c on adhesive capsulitis was significant; for each unit of time that the HbA 1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis. Discussion Cumulative HbA 1c was associated with an increased incidence of adhesive capsulitis. This finding suggests that the effects of diabetes that predispose patients to the development of adhesive capsulitis are dose dependent. Patients with worse blood sugar control over a longer period are at an increased risk of the development of adhesive capsulitis.

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball pitchers. Variations in pitching mechanics before and after UCL reconstructive surgery are not well understood.Publicly available pitch tracking data (PITCHf/x) were compared for all Major League Baseball pitchers who underwent UCL reconstruction between 2008 and 2013. Specific parameters analyzed were fastball percentage, release location, velocity, and movement of each pitch type. These data were compared before and after UCL reconstructive surgery and compared with a randomly selected control cohort.There were no statistically significant changes in pitch selection or pitch accuracy after UCL reconstruction, nor was there a decrease in pitch velocity. The average pitch release location for 4-seam and 2-seam fastballs, curveballs, and changeups is more medial after UCL reconstruction (P .01). Four-seam fastballs and sliders showed decreased horizontal breaking movement after surgery (P .05), whereas curveballs showed increased downward breaking movement after surgery (P .05).Pitch selection, pitch velocity, and pitch accuracy do not significantly change after UCL reconstruction, nor do players who require UCL reconstruction have significantly different pitch selection, velocity, or accuracy than a randomly selected control cohort. Pitch release location is more medial after UCL reconstruction for all pitch types except sliders. Breaking movement of fastballs, sliders, and curveballs changes after UCL reconstruction.

PURPOSE OF REVIEW: Our understanding of the reverse total shoulder arthroplasty (RTSA) has grown exponentially since Grammont first introduced his design in 1985. There are a multitude of implant-related variables to consider when performing RTSA. The purpose of this article is to provide a review of these design considerations. RECENT FINDINGS: Current literature demonstrates that the traditional Grammont prosthesis has over 90% survivorship at 10 years. Despite these promising results, there have been concerns raised over the significant rate of scapular notching observed. As a result, the traditional RTSA design has been modified to minimize this complication and maximize impingement-free motion. Modern RTSA designs with a cementless, curved, short-stemmed eccentric onlay humeral component combined with a large, lateralized glenosphere placed in 10° of inferior tilt with > 3.5 mm of inferior overhang have been found to provide excellent results. However, all implant design features must be considered on a case-by-case basis to optimize outcome for each patient. SUMMARY: Humeral and glenoid implant design variables have evolved as the biomechanics of RTSA have been further elucidated. Consideration of these variables allows the surgeon to maximize joint efficiency, improve impingement-free range of motion, decrease the risk of scapular notching, preserve bone stock, and minimize the risk of instability.

Orthopaedic injuries can significantly impact the careers of professional tennis players. It is currently unknown how professional tennis players fare after arthroscopic surgery. For the purpose of this study, players ranked in the Association of Tennis Professionals (ATP) and Women’s Tennis Association (WTA) who underwent arthroscopic surgery of any joint between 1996 and 2016 were identified through a well-established, previously published protocol of injury reports and public archives. Performance statistics both before and after surgery, time to return (TTR) to play, and career length following surgery were collected for each player. Statistical analysis was performed with significance accepted at a probability value (p) of

Propionibacterium acnes, now Cutibacterium acnes, is found on skin and subcutaneous tissue and is thus hard to eradicate. Infection can result in shoulder pain but be indolent and hard to diagnose; in addition, the organism is difficult to identify requiring long-hold cultures. Despite skin preparation, and second preparation before conversion of arthroscopy to mini-open surgery, we do not yet have a way to effectively eradicate C acnes from deeper dermal layers.

Background: A preexisting rotator cuff tear may affect the draft status and career performance of National Football League (NFL) players. Hypothesis: Preexisting rotator cuff tears decrease a player’s draft status, performance, and longevity in the NFL. Study Design: Retrospective cohort study. Level of Evidence: Level 3. Methods: Medical reports of prospective NFL players during the NFL Scouting Combine from 2003 to 2011 were evaluated to identify players with a previous rotator cuff tear. Athletes were matched to control draftees without documented shoulder pathology by age, position, year drafted, and round drafted. Career statistics and performance scores were calculated. Results: Between 2003 and 2011, 2965 consecutive athletes were evaluated. Forty-nine athletes had preexisting rotator cuff tears: 22 athletes underwent surgical intervention for their tear and 27 were treated nonoperatively. Those with a rotator cuff tear were significantly less likely to be drafted than those without a previous injury (55.1% vs 77.5%, P = 0.002). The 27 drafted athletes with preexisting rotator cuff tears started significantly fewer games (23.7 vs 43.0, P = 0.02) and played significantly fewer years (4.3 vs 5.7, P = 0.04) and significantly fewer games (47.1 vs 68.4, P = 0.04) than matched control athletes without rotator cuff tears. Conclusion: Athletes with a preexisting rotator cuff tear were less likely to be drafted and had decreased career longevity.

Background: Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed among Major League Baseball (MLB) pitchers. The etiology of UCL injury is complex and is not entirely understood. Hypothesis: To better understand risk factors for requiring UCL reconstruction, we hypothesized that pitchers who eventually undergo the procedure will exhibit different throwing mechanics as measured by pitch-tracking data points, such as velocity and release location. Study Design: Case-control study; Level of evidence, 3. Methods: Pitch-tracking and demographic data were gathered for 140 MLB pitchers who had undergone UCL reconstruction between the 2010 and 2017 seasons. Pitch type, release location, and velocity were compared between the surgical cohort and a matched-control cohort. Results: When compared with controls, the mean pitch release location for pitchers who required UCL reconstruction was 12.2 cm more lateral in the year immediately preceding surgery ( P = .001). Furthermore, within the surgical cohort, the horizontal release location was 3.4 cm more lateral immediately preceding surgery compared with 2 years earlier ( P = .036). Binary logistic regression indicated an odds ratio of 0.51, suggesting a roughly 5% increased odds of UCL reconstruction for every 10 cm of increased lateral release location ( P = .048). Both the surgical and the control cohorts threw similar rates of fastballs and had similar mean pitch velocity and fastball velocity. Control pitchers displayed a significant decrease over time in mean pitch velocity ( P = .005) and mean fastball velocity, while pitchers in the UCL reconstruction cohort did not ( P = .012). Conclusion: Pitch tracking indicates that the mean release point is more lateral in pitchers preceding UCL reconstruction as compared with controls, suggesting that a more lateral pitch release location is an independent risk factor for UCL injury and reconstruction.

Background Shoulder arthroscopy is a common orthopedic procedure typically performed on an outpatient basis. Occasionally, patients require an unplanned hospital admission. An understanding of the incidence and risk factors for admission after shoulder arthroscopy may assist surgeons in determining which patients may be susceptible to unplanned admission after surgery. Methods All consecutive shoulder arthroscopy procedures performed during a 10-year period were reviewed. A 2:1 control-case matching technique was used. Univariate analysis was performed to identify differences between patients admitted after surgery and the control group. Multivariate analysis was performed to identify variables associated with admission. Results There were 5598 arthroscopic shoulder procedures performed, with 233 patients (4.2%) requiring admission. The most common reason for admission was respiratory monitoring. Risk factors for admission by multivariate analysis were chronic obstructive pulmonary disease (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.51-4.95), diabetes (OR, 2.11; 95% CI, 1.28-3.48), obstructive sleep apnea (OR, 1.90; 95% CI, 1.13-3.21), age (OR, 1.02; 95% CI, 1.01-1.04), body mass index (OR, 1.04; 95% CI, 1.01-1.07), and operative time (OR, 1.01; 95% CI, 1.00-1.01). Regional with monitored anesthesia care decreased risk compared with general anesthesia and regional with general anesthesia (OR, 0.44; 95% CI, 0.30-0.63). Conclusion Chronic obstructive pulmonary disease, obstructive sleep apnea, diabetes, increasing age, increasing body mas index, and increasing operative time were all risk factors for admission after shoulder arthroscopy. The absence of general anesthesia was found to decrease the risk of admission.

Previous studies have shown no correlation between adhesive capsulitis and hemoglobin AA retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbACumulative HbACumulative HbA

Background: Pectoralis major ruptures are closely associated with weight lifting and participation in sports. The anatomy of the pectoralis major tendon is unique with an elongated thin footprint requiring multiple points of fixation to restore the native anatomy. Multiple options exist for tendon repairs, but the strongest construct has yet to be identified. Purpose: The intent of this study was to compare the load to failure of bone trough, cortical button, and suture anchor repairs of the pectoralis major tendon in the extended and abducted position. Study Design: Controlled laboratory study. Methods: Thirty fresh-frozen cadaveric shoulders were divided equally into 3 groups based on the repair technique to be performed. Bone mineral density of the surgical neck of the proximal humerus was assessed before each repair. Bone trough, suture anchor, and cortical button repairs were performed as dictated by computerized randomization. Each specimen was loaded to failure and mode of failure was noted. Results: The majority of failures occurred through the suture used for tendon repair. One specimen in the bone trough group failed via fracture of the proximal humerus. The suture anchor group failed at the implant in 5 of 9 specimens and through the suture in 4 of 9 specimens. Load to failure was greatest in bone trough repairs at 596 N, followed by cortical button at 494 N, and finally suture anchor repairs with 383 N. Load to failure was significantly greater in the bone trough group when compared with suture anchor repairs ( P = .007). No correlation was found between bone mineral density and load to failure. Conclusion: Bone trough repair of the pectoralis major tendon was stronger than suture anchor repair. Clinical Relevance: Identification of the strongest repair may help guide surgical repair.

Hypothesis Deep infection after shoulder surgery is a rare but devastating problem. This study tested the hypothesis that the home application of a 2% chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a standard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder. Materials and methods This randomized, prospective study evaluated 100 consecutive patients undergoing shoulder surgery. Patients were randomly assigned to use 2% chlorhexidine gluconate–impregnated cloths (treatment group) or to shower with soap and water before surgery (control group). Cutaneous cultures were taken from the patients’shoulders in the preoperative holding area. Patients were monitored for 2 months postoperatively for clinical signs of infection. Results In the treatment group vs the control group, the overall positive culture rate was 66% vs 94% ( P = .0008), and the positive culture rate for coagulase-negative Staphylococcus was 30% vs 70% ( P = .0001). The positive culture rate for Propionibacterium acnes was 46% in the treatment group vs 58% in the control group ( P = .32). No infections occurred in any patients at a minimum of 2-months after surgery. Discussion The use of the 2% chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus , a known causative agent of postoperative shoulder infections. Conclusion Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies.

Infection after shoulder surgery is rare but potentially devastating. Normal skin flora, including Staphylococcus aureus, Staphylococcus epidermidis, and Propionibacterium acnes, are the most commonly isolated pathogens. Perioperative measures to prevent infection are of paramount importance, and clinical acumen is necessary for diagnosis. Superficial infections may be managed with local wound measures and antibiotics; deep infections require surgical débridement in combination with antibiotic treatment. Treating physicians must make difficult decisions regarding antibiotic duration and the elimination of the offending organisms by resection arthroplasty, direct implant exchange, or staged revision arthroplasty. Eradication of a deep infection is usually successful, but the course of treatment is often protracted, and tissue destruction and scar may adversely affect functional outcome.

Background: Reverse shoulder arthroplasty changes the center of rotation (COR) of the glenohumeral joint and in doing so affects the resting tension in the deltoid and residual cuff muscles, as well as their respective moment arms. The purpose of this study was to assess the change in COR from the preoperative to postoperative state in a group of patients undergoing reverse shoulder arthroplasty. Materials and methods: The position of the COR in relation to a scapular coordinate system was determined for the anteroposterior and axillary radiographs before and after reverse total shoulder arthroplasty for 68 shoulders (63 patients) receiving either a Delta prosthesis or an Encore Reverse Shoulder Prosthesis. Results: Preoperatively, the COR was superiorly displaced a mean of 9 � 7 mm from the origin of the coordinate system. For all shoulders, the postoperative COR was inferiorly displaced by 12 mm to a position 3 � 3 mm below the coordinate origin (P < .001) and medially displaced by 27 � 4 mm from the coordinate origin (P < .001) in the anteroposterior projection. For the shoulders receiving the Delta prosthesis, the COR was inferiorly displaced by 2 � 3 mm from the coordinate origin, whereas it was inferiorly displaced by 7 � 3 mm with the Encore prosthesis (P < .001). The COR was medially displaced by 28 � 4 mm with the Delta prosthesis and by 19 � 3 mm with the Encore prosthesis (P < .001). Conclusions: The position of the COR relative to the scapula is significantly altered by reverse shoulder arthroplasty and is significantly different for 2 different implant designs. Level of evidence: Basic Science Study, Anatomic/Radiologic Study. 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.

Objectives: Medial ulnar collateral ligament reconstruction (UCLR) is a common procedure performed for Major League Baseball (MLB) pitchers. The etiology of UCL injury is complex and not entirely understood. The purpose of this study was to use publically available pitch tracking technology (PITCHf/x) to compare the pre-injury throwing mechanics of MLB pitchers who require UCL reconstructive surgery with those of pitchers who have never undergone UCL reconstruction. Methods: Pitch tracking and demographic data on MLB pitchers who had undergone UCL reconstruction between the 2010 and 2017 seasons was gathered. Pitchers were excluded if they did not throw 100 total pitches in each of the three years prior to surgery. Furthermore, only pitch types that a given pitcher utilized more than 25 times in each of the three years prior to surgery were included for individual analysis. Pitch type, release location, and velocity were compared between the UCL reconstructive surgery cohort and a matched-control cohort. Results: The average pitch release location for pitchers who required UCL reconstruction was more lateral in the two years immediately preceding surgery than the control cohort (p=0.001 and p=0.023). Furthermore, a time-based comparison between the year immediately preceding surgery and two years prior showed a more lateral release immediately prior to surgery (p=0.036). Pitchers who required UCL reconstruction throw similar rates of fastballs as the control cohort and the average pitch velocity and fastball velocity were similar between the UCL group and the control group. The control pitchers displayed a significant decrease in average pitch velocity (p=0.005) and average fastball velocity (p=0.012) over the period of the study. Conclusion: Pitch tracking indicates pitch selection and pitch velocity are similar before that the average release point is more lateral preceding UCL reconstruction as compared to the control cohort suggesting that pitch release location might be an independent risk factor for UCL injury and reconstruction. On the other hand, pitch selection and pitch velocity are similar between these cohorts. Powerful technology including PITCHf/x allows for accurate monitoring of factors such as arm position and could potentially be used to identify pitchers at risk for UCL rupture. Figure 1 Average pitch release location with error bars for standard eror of the mean. Location is measured as feet from the center of the mound, and left-handed pitchers are normalized to the right handed pitcher. UCL pitchers (dark grey) have a significantly more lateral and lower release locations in Year I (the year immediately prior to surgery) than did the control group (light grey). Furthrmore, the release location of UCL pitchers is more lateral in the Year I than in Year III.

Deep infection following shoulder surgery is a rare but devastating problem. The use of an effective skin-preparation solution may be an important step in preventing infection. The purposes of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder.A prospective study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution. Each shoulder was prepared with one of three randomly selected solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodophor and 74% isopropyl alcohol), or povidone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint). Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients, to determine the native bacteria around the shoulder, and following skin preparation for all patients.Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures was 31% in the povidone-iodine group, 19% in the DuraPrep group, and 7% in the ChloraPrep group. The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group (p0.0001) and the DuraPrep group (p = 0.01). ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region (p0.001 for both). No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region. No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up.ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region. Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder.

Objectives: Fifty percent of all athletes at the National Football League (NFL) Combine report having had a shoulder injury at some point during their playing career. Rotator cuff tears are rare injuries in young athletes, but an increasing incidence has been noted amongst competitive football players. It is unknown how pre-existing rotator cuff tears affect career longevity and performance of NFL athletes. In Combine athletes with pre-existing rotator cuff tears, knowledge of outcomes may help athletes and physicians manage expectations of draft potential, career length and performance. Methods: The written medical evaluations of prospective professional American football athletes from 2003-2011 during the NFL Combine were compiled and evaluated. All players were evaluated for the diagnosis of a pre-existing rotator cuff tear and stratified based on whether or not they underwent surgical intervention. Athletes with rotator cuff tears, who were selected in the NFL draft, were matched by age, position, year, and round drafted to control draftees without significant documented shoulder pathology. Career statistics, including a previously established “Performance Score,” were compiled. The continuous variables of each cohort were compared using a Student's t-test. A Chi Squared test was performed to analyze the categorical data. Statistical significance was accepted with a p-value < 0.05. Results: Between the years of 2003 and 2011, 2,965 consecutive athletes were evaluated. Forty-nine athletes were identified with a pre-existing rotator cuff tear; twenty-two of these athletes underwent surgical intervention for their tear and 27 were treated non-operatively. Those who attended the NFL Combine with a history of a rotator cuff tear were significantly less likely to be drafted than those without a previous injury (55.1% vs. 77.5% respectively, p = 0.002) (Table 1A). The 27 drafted athletes with pre-existing rotator cuff tears played significantly fewer years (4.3 vs. 5.7, p=0.04) and significantly fewer games (47.1 vs. 68.4, p=0.04) than matched control athletes without rotator cuff tears (Table 1B). Additionally, these athletes started significantly fewer games (23.7 vs. 43.0, p=0.02) and had significantly worse performance scores (0.97 vs. 1.33, p=0.01) when compared to controls. When comparing those who had surgical intervention on their rotator cuff tears with those treated non-operatively, there were no statistically significant differences identified in outcome measures, including round drafted (3.7 vs. 4.8, p=0.17) and performance score (0.18 vs. 1.36, p=0.16) (Table 1C). Conclusion: NFL athletes with pre-existing rotator cuff tears were less likely to be drafted. Those drafted had decreased career longevity as well as diminished career performance when compared to matched control players. Additionally, athletes who had previous surgical intervention on a torn rotator cuff trended toward a worse draft status and career performance score, but these results were not statistically significant. Players with rotator cuff tears, regardless of whether or not they had surgery, demonstrated significantly shortened careers and decreased performance scores compared to players without rotator cuff tears. These results will help both players and physicians at the NFL Combine manage expectations of draft potential, career longevity and success.

Background:Bone-bridging (arthrodesis of the distal tibia and fibula) at the time of transtibial amputation is a controversial operative technique that is anecdotally reported to improve the weightbearing capacity of the residual limb and to decrease residual limb discomfort.Methods:Thirty-two consecutive patients with multiple diagnoses had transtibial amputation with a distal tibial-fibular bone-bridge, all done by a single surgeon (MAP). At an average of 16.3 months after surgery all patients completed the Prosthetics Evaluation Questionnaire (PEQ), a validated outcomes instrument specifically created to evaluate quality of life and functional demands in patients with a lower extremity amputations. Their responses were compared with those of 17 preselected, highly functional transtibial amputees from two academic medical centers who previously had transtibial amputations using a traditional non bone-bridge operative technique; their time since amputation averaged 14.7 years.Results:The “nonselected” consecutive patients with a bone-bridged residual limb scored higher (more favorable) in the Ambulation ( p = 0.037) and Frustration ( p < 0.001) domains of the PEQ and lower (less favorable) in the Appearance ( p = 0.025) subscale. Their scores were similar in the other six domains.Conclusions:Patients of multiple ages with multiple diagnoses who had bone-bridging of the distal tibia and fibula at the time of transtibial amputation had scores on a validated outcomes instrument that were better than or comparable to those of a selected group of highly functional transtibial amputees. The results of this study suggest that bone-bridging at the time of transtibial amputation may enhance patient-perceived functional outcomes.

Previous studies investigating acromioclavicular (AC) joint injuries in professional American football players have only been reported on quarterbacks during the 1980s and 1990s. These injuries have not been evaluated across all position players in the National Football League (NFL).The purpose of this study was 4-fold: (1) to determine the incidence of AC joint injuries among all NFL position players; (2) to investigate whether player position, competition setting, type of play, and playing surface put an athlete at an increased risk for this type of injury; (3) to determine the incidence of operative and nonoperative management of these injuries; and (4) to compare the time missed for injuries treated nonoperatively to the time missed for injuries requiring surgical intervention.Descriptive epidemiological study.All documented injuries of the AC joint were retrospectively analyzed using the NFL Injury Surveillance System (NFLISS) over a 12-season period from 2000 through 2011. The data were analyzed by the anatomic location, player position, field conditions, type of play, requirement of surgical management, days missed per injury, and injury incidence.Over 12 NFL seasons, there were a total of 2486 shoulder injuries, with 727 (29.2%) of these injuries involving the AC joint. The overall rate of AC joint injuries in these athletes was 26.1 injuries per 10,000 athlete exposures, with the majority of these injuries occurring during game activity on natural grass surfaces (incidence density ratio, 0.79) and most often during passing plays. These injuries occurred most frequently in defensive backs, wide receivers, and special teams players; however, the incidence of these injuries was greatest in quarterbacks (20.9 injuries per 100 players), followed by special teams players (20.7/100) and wide receivers (16.5/100). Overall, these athletes lost a mean of 9.8 days per injury, with quarterbacks losing the most time to injury (mean, 17.3 days). The majority of these injuries were low-grade AC joint sprains that were treated with nonoperative measures; only 13 (1.7%) required surgical management. Players who underwent surgical management lost a mean of 56.2 days.Shoulder injuries, particularly those of the AC joint, occur frequently in the NFL. These injuries can result in time lost but rarely require operative management. Quarterbacks had the highest incidence of injury; however, this incidence is lower than in previous investigations that evaluated these injuries during the 1980s and 1990s.

Background: The presence of multiple allergies has been correlated with worse outcomes for patients undergoing hip and knee arthroplasty, but the effect of allergies has not yet been elucidated with respect to shoulder arthroplasty. Purpose/Hypothesis: The purpose of this study is to identify any discrepancies in shoulder arthroplasty outcomes with respect to reported drug allergies. We hypothesized that patients with multiple drug allergies would have inferior outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the analysis were a single surgeon’s cases between 2009 and 2014 of primary total shoulder arthroplasty with a minimum of 180 days of follow-up. Cases with fracture as the indication were excluded. Preoperative and postoperative metrics included visual analog scale (VAS) for pain, forward flexion range of motion, and Simple Shoulder Test (SST) results, and postoperative patient satisfaction scores were also collected. Chi-square and 1-way analysis of variance with Tukey post hoc analyses were performed when appropriate. Results: A total of 98 patients were included (no allergies, n = 51; single allergy, n = 21; multiple allergies, n = 26). The proportion of females was greater with increasing number of allergies (no allergies, 31%; single allergies, 47%; multiple allergies, 88%; Pearson χ2 = 22.5; P < .0001). Both preoperatively and postoperatively, no difference was found between cohorts with respect to SST score, VAS score, or forward flexion. There was also no difference in postoperative satisfaction between cohorts. No difference between cohorts was identified when comparing the pre- to postoperative change in SST scores, VAS scores, or forward flexion. Conclusion: The presence of single or multiple allergies is not correlated with worse outcomes after primary anatomic total shoulder arthroplasty.

Background: Attritional bone loss in patients with recurrent anterior instability has successfully been treated with a bone block procedure such as the Latarjet. It has not been previously demonstrated whether cortical or cancellous screws are superior when used for this procedure. Purpose: To assess the strength of stainless steel cortical screws versus stainless steel cannulated cancellous screws in the Latarjet procedure. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen matched-pair shoulder specimens were randomized into 2 separate fixation groups: (1) 3.5-mm stainless steel cortical screws and (2) 4.0-mm stainless steel partially threaded cannulated cancellous screws. Shoulder specimens were dissected free of all soft tissue and a 25% glenoid defect was created. The coracoid process was osteomized, placed at the site of the glenoid defect, and fixed in place with 2 parallel screws. Results: All 10 specimens failed by screw cutout. Nine of 10 specimens failed by progressive displacement with an increased number of cycles. One specimen in the 4.0-mm screw group failed by catastrophic failure on initiation of the testing protocol. The 3.5-mm screws had a mean of 274 cycles (SD, ±171 cycles; range, 10-443 cycles) to failure. The 4.0-mm screws had a mean of 135 cycles (SD, ±141 cycles; range, 0-284 cycles) to failure. There was no statistically significant difference between the 2 types of screws for cycles required to cause failure ( P = .144). Conclusion: There was no statistically significant difference in energy or cycles to failure when comparing the stainless steel cortical screws versus partially threaded cannulated cancellous screws. Clinical Relevance: Latarjet may be performed using cortical or cancellous screws without a clear advantage of either option.

Glenoid component loosening is a common complication of total shoulder arthroplasty and has been associated with the progression of radiolucent lines at the glenoid bone–cement interface. Generation of heat during the exothermic reaction of cement curing may cause osteonecrosis of bone, potentially leading to the development of radiolucent lines. The purpose of this study was to measure the heat generated with various defined amounts of cement used for glenoid component fixation. Ten fresh-frozen cadaver scapulas were randomized to receive a keeled or pegged component with 1, 2, 3, 5, or 7 g of cement for fixation. An infrared camera was used to record the surface temperature generated during the cement curing process to an accuracy of ±2.0°C. Computed tomography was used to evaluate the cement mantle. The maximum temperatures generated did not exceed the critical value for osteonecrosis (56°C) in any of the specimens. The 4 specimens without a complete mantle were those fixed with a smaller quantity of cement (1, 2, or 3 g), and the largest cement mantle thicknesses were observed with the use of 7 g of cement. Up to 7 g of cement can be used without significant concern for thermal necrosis. Incomplete cement mantles were observed when ⩽3 g of cement was used for fixation. Our results suggest that surgeons should use >3 g of cement to avoid incomplete cement mantles and that up to 7 g of cement can safely be used for glenoid fixation.

Background: Frequently, patients who are candidates for reverse shoulder arthroplasty have had prior surgery that may compromise the anterior deltoid muscle. There have been conflicting reports on the necessity of the anterior deltoid thus it is unclear whether a dysfunctional anterior deltoid muscle is a contraindication to reverse shoulder arthroplasty. The purpose of this study was to determine the 3-dimensional (3D) moment arms for all 6 deltoid segments, and determine the biomechanical significance of the anterior deltoid before and after reverse shoulder arthroplasty. Methods: Eight cadaveric shoulders were evaluated with a 6-axis force/torque sensor to assess the direction of rotation and 3D moment arms for all 6 segments of the deltoid both before and after placement of a reverse shoulder prosthesis. The 2 segments of anterior deltoid were unloaded sequentially to determine their functional role. Results: The 3D moment arms of the deltoid were significantly altered by placement of the reverse shoulder prosthesis. The anterior and middle deltoid abduction moment arms significantly increased after placement of the reverse prosthesis (P < .05). Furthermore, the loss of the anterior deltoid resulted in a significant decrease in both abduction and flexion moments (P < .05). Conclusion: The anterior deltoid is important biomechanically for balanced function after a reverse total shoulder arthroplasty. Losing 1 segment of the anterior deltoid may still allow abduction; however, losing both segments of the anterior deltoid may disrupt balanced abduction. Surgeons should be cautious about performing reverse shoulder arthroplasty in patients who do not have a functioning anterior deltoid muscle. Level of Evidence: Basic Science Study, Biomechanics, Cadaver Model. 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

Magnetic resonance imaging (MRI) is capable of producing images in any anatomical plane, visualizing and analyzing a variety of tissue characteristics, as well as quantifying blood flow and metabolic functions. Although MRI details of compact bone and calcium are poor when compared to those taken with plain radiography or computed tomography, its high soft tissue contrast discrimination and multiplanar imaging capabilities are significant advantages. Musculoskeletal anatomy and neurovascular bundles are well delineated. The advent of MRI has revolutionized the clinician's ability to confirm a proper diagnosis for musculoskeletal problems, which has led to more directed, specific rehabilitative protocols. However, the value of MRI to rehabilitative professionals has been even greater in its ability to identify serious, more uncommon pathologies, such as in those with underlying infection, fracture, or tumor, that require immediate care and are considered to be beyond their scope of practice. Furthermore, MRI, with its precise delineation of fat, muscle, and bone, is an ideal candidate for imaging of muscle disease or injury and has emerged as the method of choice for the detection of early cartilage wear in young patients, such as osteoarthritis. Finally, this imaging modality can avoid radiation exposure in a predominantly younger patient cohort commonly affected by musculoskeletal diseases. The aim of this paper is to consider how physical therapists may take advantage of the diagnostic value of MRI of the upper limb, while avoiding the pitfalls of misinterpretation of images as a result of technical issues, pathological changes, or normal variants.

As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. Histologic studies have shown that restoration of the rotator cuff footprint during repair can help reestablish the enthesis. In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.

Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.¹⁻⁷ These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them. This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.

Recent articles in this journal showed the clinical importance of the position of the humeral head center in relation to the glenoid. However, the precision, reproducibility, and sensitivity of this and other methods of documenting the head center position have not been evaluated in detail.We used templates to fit a coordinate system to the scapular anatomy visible on standardized radiographs. Two observers then used these templates to measure the position of the head center relative to this coordinate system on 25 normal shoulder radiographs and on 25 radiographs of shoulders with cuff tear arthropathy (CTA).Head center measurements had excellent precision. Normal shoulder radiographs showed a consistent head center position (0.7 ± 1.7 mm medial and 0.6 ± 1.3 mm inferior to the coordinate origin on the anteroposterior view and 0.1 ± 1.3 mm medial and 0.0 ± 1.3 mm anterior to the coordinate origin on the axillary view). The head center of CTA shoulder radiographs was 10.18 ± 5.16 mm above the coordinate origin on the anteroposterior view, significantly different from that for the normal shoulder radiographs (P.001).The relative position of the humeral head center to the scapula determines the resting length and the moment arms of the scapulohumeral muscles. Correlation of shoulder function with the head center position may provide insights into both shoulder pathomechanics and the optimization of shoulder arthroplasty.This practical technique showed a high degree of precision and reproducibility for normal and CTA shoulder radiographs as well as a high level of discrimination between these two groups.

Glenohumeral arthritis in younger individuals is challenging because of the complex pathology, need for extended durability, and high expectations of the patients. Humeral hemiarthroplasty combined with concentric glenoid reaming is a surgical option for the management of glenohumeral arthritis that avoids the risks of glenoid component failure and avoids the challenges of tissue interposition. The results of this procedure in young patients have not been previously reported.Sixty-five shoulders in patients who were 55 years old or less at the time of surgery underwent humeral hemiarthroplasty combined with concentric glenoid reaming and were followed for a minimum of 2 years or until the time of revision surgery. Patient self-assessments of shoulder comfort and function were compared before and after surgery. For 22 of these shoulders, standardized radiographs were available for follow-up evaluation.Nine shoulders required revision surgery. These shoulders had 3 ± 3 prior surgeries, in comparison to 1 ± 1 prior surgeries for the unrevised group. For the 56 unrevised shoulders, the number of Simple Shoulder Test functions that could be performed improved from a mean of 4.1 before surgery to a mean of 9.5 at an average follow-up of 43 months (range, 24-85) (P.001). For the 22 shoulders with radiographic follow-up, medial glenoid erosion averaged 1.1 mm (range, 0.0-6.3 mm) at an average of 44 months after the procedure.In selected patients 55 years or younger with glenohumeral arthritis, this procedure can provide significant improvement in self-assessed shoulder comfort and function.

Hypothesis Glenoid erosion and medial migration of the humeral head prosthesis have been observed after most types of shoulder arthroplasty. A method of measuring the change in humeral head position with time after shoulder prosthetic arthroplasty was applied it to 14 shoulders that underwent humeral hemiarthroplasty with concentric glenoid reaming. We hypothesized that the measurement technique would be reproducible and that the rate of wear would be small in the series of shoulders studied. Materials and methods Standardized anteroposterior and axillary radiographs were obtained after surgery. Two examiners measured the position of the humeral head center in relation to scapular reference coordinates for the anteroposterior and axillary projections and plotted these values against time after surgery. The change in position was characterized as the slope of this plot. Shoulders were included if there were at least 3 sets of postoperative films, the last being at least 2 years after surgery. Results The slopes measured by the 2 examiners agreed within 0.5 mm/y for the anteroposterior and the axillary projections. For the series of shoulder arthroplasties, the rate of movement of the head center toward the scapula was less than 0.4 mm/y for either examiner in either projection. Discussion Medial migration is a concern after any type of shoulder arthroplasty, whether a hemiarthroplasty, a biological interpositional arthroplasty, or a total shoulder arthroplasty. Quantifying the rate of medial migration over time after shoulder arthroplasty is an important element of clinical follow-up. Conclusions This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. The average rate of medial migration in the shoulders in this study was small.

Background: The reported outcomes of shoulder arthroplasty in patients under the age of fifty years are worse than those in patients over fifty. While there are several possible explanations for this finding, we explored the possibility that patients who had a primary shoulder arthroplasty when they were under fifty years of age differed from those who had the procedure when they were over fifty with respect to their pre-arthroplasty self-assessed comfort and function, sex distribution, and specific type of arthritis. Methods: The study group consisted of patients with glenohumeral arthritis who were treated with a primary shoulder arthroplasty by the same surgeon between 1990 and 2008. For each decade of age, the sex distribution, the pre-arthroplasty self-assessed shoulder comfort and function, and the prevalence of twelve different diagnoses were documented. We reviewed the series for three potential causes of worse outcomes in patients under fifty years of age as compared with those over fifty years of age: (1) a higher percentage of women, (2) a lower score for pre-arthroplasty self-assessed comfort and function, and (3) more complex pathological conditions. Results: Patients under the age of fifty years were not more likely than those over fifty to be female or to have a lower pre-arthroplasty self-assessed comfort and function score, but they did have more complex pathological conditions, such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. This difference was significant (p < 0.000000001). Conclusions: Surgeons performing shoulder arthroplasty in individuals under the age of fifty should be prepared to encounter pathological conditions such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis rather than primary osteoarthritis, which is more common in individuals older than fifty. The pathoanatomy in these younger patients may complicate the surgery, the rehabilitation, and the outcome of the shoulder arthroplasty.

There are multiple reports in the literature of chondrolysis following arthroscopic shoulder surgery. Although the etiology of these cases is not known for certain, there has been speculation that radiofrequency devices, young patient age, instability surgery, intra-articular pain pumps, and type of anesthetic may be precipitating factors. This article describes a case of a 37-year-old law enforcement officer who injured both shoulders and ultimately underwent nearly identical bilateral procedures: arthroscopic superior labrum anteroposterior (SLAP) repair, Bankart repair, capsulorrhaphy, acromioplasty, and distal clavicle excision. Intra-articular pain catheters were placed following both procedures, but the right-sided catheter never functioned properly, as evidenced by continuous leakage outside of her body until it was removed. Subsequently she had an arthroscopic lysis of adhesions done for residual stiffness, in which the left humeral head and glenoid cavity were noted to be completely devoid of articular cartilage. Over the ensuing months, multiple cortisone injections, 5 viscosupplementation injections, physical therapy, and narcotics all failed to relieve her left shoulder pain. Radiographs showed significant left glenohumeral joint space narrowing and a normal-appearing joint space on the right. Our impression was postsurgical chondrolysis of the left shoulder. The patient has recently undergone humeral hemiarthroplasty with nonprosthetic glenoid arthroplasty. This case differs from others reported in the literature in that nearly identical bilateral procedures were performed by the same surgeon, yet chondrolysis only developed on the side that had a functioning postoperative pain catheter.

We present the case of a professional horse jockey with chronic, bilateral, posterior sternoclavicular dislocations. Traumatic dislocation of the sternoclavicular is a relatively rare but potentially devastating injury. Posterior sternoclavicular dislocations occur less frequently than anterior dislocations and require careful and complete evaluation because of the potential for serious complications including respiratory distress, brachial plexus injury, and vascular injury. Our patient was treated with excision of the medial end of the clavicle on her symptomatic side.

Vitamin A is necessary for synthesis of visual pigments and required in appropriate amounts for membrane stability. Acute hypervitamin A intoxication can lead to increased intracranial pressure, vomiting, and lethargy. Chronic excessive intake of vitamin A can lead to pruritis, muscle and bone tenderness, and failure to thrive. Reported effects of hypervitamin A intoxication on bone include osteoporosis, fracture, cortical thickening, and metaphyseal irregularity. We are reporting on a case of central physeal arrest in the distal femur, proximal tibia, and distal tibia after excessive intake of vitamin A.