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Vani Sabesan,1 Zachary Steffes,2 Daniel J Lombardo,1 Graysen R Petersen-Fitts,1 Toufic R Jildeh2 1Department of Orthopaedic Surgery, 2Wayne State University School of Medicine, Detroit, MI, USA Abstract: Rugby participation in the US is increasing, and with its inclusion in the 2016 Summer Olympics, the increased participation rates are expected to continue. Naturally, as participation increases, so too do rugby-related injuries. The difference in injury patterns with regard to age and gender illustrates differences in how the game is being played. Understanding what accounts for these emerging injury patterns will help guide future injury prevention efforts. This study provides an update on injury rates for the growing population of rugby players in the US, especially young players. Our results focus on the variation of injury types and the injury rates of various levels of rugby players, including youth, collegiate, and recreational. Using injury data from the National Electronic Injury Surveillance System, we analyzed data in rugby patients for age, gender, body region, type of injury, and severity. We employed statistical weights to calculate national injury estimates. During the 10 years studied, the trend in the number of rugby injuries among all age groups showed a statistically significant increase (R=0.804, P=0.005). The average age of injury was 21.5±6.3 years with facial and head injuries constituting >33% of all injuries, representing a proportional increase of >10%. Men were most frequently injured in the face (18.2%) and head (15.9%); women were most frequently injured in the head (23%) and shoulder (12.3%). There were 9,059 concussions, constituting 7% of all injuries. Keywords: rugby, injury pattern, epidemiology

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Preoperative opioid use has been correlated to suboptimal outcomes in orthopedic surgery. This study evaluated the effect of preoperative opioid use on outcomes after arthroscopic rotator cuff repair (RCR)., Methods: A retrospective review was performed of 79 patients who underwent arthroscopic RCR; of these, 31 with a history of preoperative opioid use were compared with a control group of 48 patients without a history of preoperative opioid use. Preoperative and postoperative patient-reported outcomes and functional scores were compared., Results: Both cohorts significantly improved on all patient-reported shoulder scores; however, the nonopioid group demonstrated significantly better postoperative patient-reported outcome scores ( P  = .015) and external rotation measurement ( P  = .008). Functional outcomes also significantly improved from preoperatively to postoperatively for forward flexion, but no differences were seen between groups., Conclusions: Patients with a history of preoperative opioid use can still achieve significant improvements in outcomes after arthroscopic RCR, although not to the same extent as opioid-naïve patients. Therefore, orthopedic surgeons must consider a patient's preoperative opioid use and temper expectations with regard to outcomes so that they are able to set realistic postoperative goals for patients undergoing RCR.

Background: Shoulder arthroplasty is the fastest growing joint replacement surgery in the United States, and optimal postoperative pain management is critical to optimize outcomes for these surgeries. Liposomal bupivacaine (LB) has gained popularity for its potential to provide extended postoperative pain relief with possibly fewer side effects. The goal of this study was to assess the impact of LB compared with continuous interscalene nerve block (CISB) in terms of postoperative pain control, outpatient pain scores, and patient-reported and functional outcomes after shoulder arthroplasty surgery., Methods: A prospective randomized controlled clinical trial compared consecutive patients undergoing shoulder arthroplasty treated with CISB vs. LB with a single bolus interscalene block. The primary outcome measures included pain assessment up to 24 hours after surgery; in addition, all doses and times of narcotics administered during the inpatient stay were recorded. Patient-reported outcome measures for pain, satisfaction, and functional outcomes were recorded postoperatively., Results: A total of 70 of 74 consecutive patients who underwent shoulder arthroplasty were included in the study. The LB group had equivalent narcotic use, pain scores, and time to first narcotic rescue compared with the CISB group within the first 24 hours (P > .05). The LB group had higher American Shoulder and Elbow Surgeons score and Penn Shoulder Score at final follow-up. There was an increased number of complications and cost for the CISB group., Conclusion: This prospective randomized controlled trial demonstrated that LB provides excellent postoperative pain relief for shoulder arthroplasty patients. In addition, LB had fewer complications and lower cost, making it a promising addition to a multimodal pain regimen for shoulder arthroplasty., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Manufacturers of reverse shoulder arthroplasty (RSA) implants have recently designed innovative implants to optimize performance in rotator cuff-deficient shoulders. These advancements are not without tradeoffs and can have negative biomechanical effects. The objective of this study was to develop an integrated finite element analysis-kinematic model to compare the muscle forces and joint reaction forces (JRFs) of 3 different RSA designs., Methods: A kinematic model of a normal shoulder joint was adapted from the Delft model and integrated with the well-validated OpenSim shoulder model. Static optimizations then allowed for calculation of the individual muscle forces, moment arms, and JRFs relative to net joint moments. Three-dimensional computer models of 3 RSA designs-humeral lateralized design (HLD), glenoid lateralized design, and Grammont design-were integrated, and parametric studies were performed., Results: Overall, there were decreases in deltoid and rotator cuff muscle forces for all 3 RSA designs. These decreases were greatest in the middle deltoid of the HLD model for abduction and flexion and in the rotator cuff muscles under both internal rotation and external rotation. The JRFs in abduction and flexion decreased similarly for all RSA designs compared with the normal shoulder model, with the greatest decrease seen in the HLD model., Conclusions: These findings demonstrate that the design characteristics implicit in these modified RSA prostheses result in mechanical differences most prominently seen in the deltoid muscle and overall JRFs. Further research using this novel integrated model can help guide continued optimization of RSA design and clinical outcomes., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The published return-to-play (RTP) rates for Major League Baseball (MLB) pitchers who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of surgical treatment for MLB players is largely unknown., Purpose: To examine the RTP rate and performance of MLB pitchers who have undergone SLAP tear repair between 2003 and 2010., Study Design: Descriptive epidemiological study., Methods: A retrospective review of MLB pitchers undergoing SLAP repair was performed using the MLB disabled list. Data collected included the following player statistics: earned run average (ERA), walks plus hits per inning pitched (WHIP), and innings pitched (IP). The mean values for performance variables both before and after surgery were compared. A definition of return to prior performance (RTPP) was established as an ERA within 2.00 and WHIP within 0.500 of preoperative values., Results: Twenty-four MLB players met inclusion criteria, of which 62.5% were able to RTP at the MLB level after SLAP repair surgery. Of those able to RTP, 86.7% were able to RTPP. However, the overall rate of RTPP, including those unable to RTP, was 54.2%. Mean performance analysis of the RTP group revealed a statistically significant decrease in IP for MLB pitchers throwing a mean 101.8 innings before injury and 65.53 innings after injury ( P = .004)., Conclusion: Of those pitchers able to RTP, chances of a full recovery were good (86.7%). Our results indicate the need for future research aimed at proper surgical selection of who will return to play, as they will likely achieve full recovery. We believe this information can help surgeons advise high-level overhead-throwing athletes about expected outcomes for surgical treatment of SLAP tears., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: V.J.S. has received research support from Exactech and is a paid consultant for Arthrex.

Purpose: Eccentric posterior bone loss and associated glenoid retroversion represent challenges to glenoid placement during total shoulder arthroplasty. This bone loss can lead to poor stability and perforation of the glenoid during arthroplasty. The purpose of this study was to evaluate the morphology of glenoid bone loss for a spectrum of osteoarthritis patients using 3D computed tomography imaging and simulation software., Methods: This study included 29 patients with glenohumeral osteoarthritis treated with shoulder arthroplasty. Three-dimensional reconstruction of preoperative CT images was performed. Glenoid bone loss was measured at ten, vertically equidistant axial planes along the glenoid surface at four distinct anterior-posterior points on each plane. The images were fitted with modeled pegged glenoid implants to predict glenoid perforation., Results: The 3D maps demonstrated greatest average bone loss posteriorly in the AP plane at the central axis of the glenoid in the SI plane. The average amount of bone loss was 3.85 mm. Walch A2 and B1 shoulders showed more central bone loss, while Walch B2 shoulders displayed more posterior and inferior bone loss. Patients with predicted peg perforation displayed significantly greater bone loss than those without predicted peg perforation (p = 0.037). Peg perforation was most common in Walch B2 shoulders occurring in the posterior direction involving the central and posterior-inferior peg., Conclusions: These data demonstrate an anatomic pattern of glenoid bone loss for different classes of glenohumeral arthritis. These findings can be used to develop various models of glenoid bone loss to guide surgeons, predict failures, and develop better glenoid implants. This study has been approved by the Cleveland Clinic IRB: Number 6235.

Due to the increased number of revision total hip arthroplasties (THAs) to correct pain secondary to fretting from modular hip stems, this study was conducted in an effort to correlate objective findings of serum cobalt (Co) levels, serum chromium (Cr) levels, and/or reactive tissue seen on metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) with a patient's need for revision THA. The study group comprised 66 patients, 18 of whom received MARS MRI. Serum Co levels, serum Cr levels, and standard numeric rating scale for pain were documented for all patients. Statistical analysis was then performed to determine whether there was a correlation between the aforementioned variables and the need for revision THA. Serum Cr levels were higher in patients with positive reactive tissue findings on MARS MRI, although this only approached significance (P=.083). Serum Co levels were higher in those undergoing revision THA, but this also only approached significance (P=.076). Pain scores were significantly different between those undergoing revision and those not (P<.001). It is the opinion of the authors that there is no objective finding in this study that can be used to identify patients who require revision THA secondary to fretting of a modular hip stem prosthesis. Only a patient's stated pain level can assist a surgeon in the decision-making process regarding the need for revision THA secondary to fretting. [Orthopedics.2016; 39(5):288-292.]., (Copyright 2016, SLACK Incorporated.)

Purpose: Reverse shoulder arthroplasty (RSA) is based on the biomechanical advantages of lengthening the deltoid while medializing its center of rotation (COR). Little evidence exists describing the clinical benefits of these biomechanical advantages. The purpose of this study is to assess the relationship between deltoid lengthening and medialization of the COR with functional outcomes for RSA patients., Methods: We retrospectively reviewed patients treated with primary RSA. Radiographic measurements of deltoid length and COR, assessment of forward elevation (FE) and external rotation (ER), and functional outcome scores were obtained pre- and postoperatively. Linear regression analyses were performed to assess the relationship between these radiographic measurements and changes in shoulder functionality., Results: On average, patients improved significantly in function and functional outcome scores. Postoperative COR correlated weakly with postoperative FE. There were weakly negative correlations between increase in acromion to greater tuberosity distance and postoperative FE, and between deltoid lengthening and FE improvement., Conclusions: Our results suggest that deltoid lengthening does not correlate with improvements in active FE or ER. These findings could indicate that change in deltoid length is less important than previously thought. Furthermore, the negative correlations seen could indicate that there is over-tensioning of the deltoid in specific cases. Further studies are needed to better assess the role of deltoid length and other factors that may impact RSA outcomes.

Purpose: Reverse shoulder arthroplasty (RSA) is an effective surgery for a variety of patients with difficult shoulder pathology. Since postsurgical outcomes are often variable, there has been great effort made to optimize the design and use of these implants. Previous studies demonstrated an association between increased glenosphere size and improved range of motion. The purpose of this study is to assess the relationship between glenosphere size, range of motion, and functional outcome scores., Methods: This is a retrospective cohort study of 140 patients (148 shoulders) undergoing reverse shoulder arthroplasty. All patients were assessed pre- and postoperatively for range of motion, Constant score, ASES score, and Subjective Shoulder Value. Improvements in these variables were compared for patients treated with three different glenosphere sizes (36, 40, 42 mm)., Results: All groups had a mean improvement in range of motion and functional outcome scores, but there were no statistically significant differences between groups when controlling for preoperative differences., Conclusions: Our findings do not support a strong role for glenosphere size as a singular factor affecting range of motion or patient-reported outcome following RSA. These problems are most likely due to the multifactorial nature of shoulder dynamics. For this reason, assessing the effect a single surgical or biomechanical parameter on function has been challenging.