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Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study is to identify pre- and postoperative factors that impact range of motion and function after augmented TSA in patients with B2 or B3 glenoid morphology.A retrospective review was performed of all patients who underwent TSA with a step type augment by a single surgeon between 2009 and 2018. Patients with a Walch type B2 or B3 glenoid were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale for pain (VAS). Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and mid-glenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to range of motion and functional outcome scores.Fifty patients (mean age, 68.1 + 8.0) with a mean follow-up of 42.0 months (Range, 24-106 months) were included. Glenoid morphology included 41 B2 and 9 B3 glenoids. One patient had center-peg osteolysis and one patient had glenoid component loosening. The average preoperative FE, ER, and IR was 110°, 21°, and S1, respectively. The average postoperative FE, ER, and IR was 155°, 42°, and L1, respectively. The mean postoperative VAS score was 0.5 + 0.8 and mean SANE score was 94.5 + 5.6. Patients with B3 glenoids were associated with better postoperative internal rotation compared to B2 glenoids (T10 vs L1, p=0.024), with no other differences in range of motion between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative range of motion. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with range of motion in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r= -0.448, p=0.006).Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative range of motion and function had no clinically important associations with pre- or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented total shoulder arthroplasties except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Recent attempts have been made to use preoperative patient-reported outcome measure (PROM) thresholds as prior authorization criteria based on the assumption that patients who have higher baseline scores are less likely to achieve the minimal clinically important difference (MCID). This study aimed to identify factors affecting the achievement of MCID and patient acceptable symptom state (PASS) after total hip arthroplasty (THA), and to determine the overlap between the two outcomes.We identified 3,581 primary, unilateral THAs performed at a single practice in 2015-2019. PROMs including Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-item Short Form Health Survey were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS according to attainment of MCID was assessed. Multivariable regression was used to identify independent predictors of MCID and PASS.In total, 79.8% achieved MCID and 73.6% achieved PASS for HOOS-JR. Approximately 1 in 7 patients who achieved MCID did not eventually achieve PASS. Worse preoperative HOOS-JR (odd ratio 0.933) was associated with MCID attainment. Better preoperative HOOS-JR (odd ratio 1.015) was associated with PASS attainment. Men, lower body mass index, better American Society of Anesthesiologists score, and better preoperative 12-item Short Form Health Survey mental score were predictors of MCID and PASS. Age, race, ethnicity, Charlson Comorbidity Index, and smoking status were not significant predictors.Preoperative PROMs were associated with achieving MCID and PASS after THA, albeit in opposite directions. Clinicians should strive to help patients "feel better" and "feel good" after surgery. Preoperative PROMs should not solely be used to prioritize access to care.

All-inorganic perovskite nanocrystals are formulated for inkjet deposition and utilised as photosensitive layers in single layer graphene and inkjet-printed graphene detectors with high photoresponse in UV-vis range.

Thousands of orthopedic surgeons in the United State face medical malpractice claims annually; however, little is known regarding the common causes for litigation against shoulder surgeons. In addition, the current analysis does not take into consideration how surgical frequency affects the litigation likelihood. The purpose of our investigation was to identify the most common causes of litigation against shoulder surgeons in the United States adjusting for surgical frequency.The VerdictSearch database was used using the search terms "medical malpractice," "shoulder," and "NOT cancer." Results were queried, and all studies pertaining to orthopedic shoulder surgery included. Data gathered included cause of lawsuit, indemnity paid, type of surgery performed, results of the cases, verdict or settlement, and, if applicable, technical error. A query of a multisurgeon institutional database was conducted to determine how frequently surgeries were performed. Then the frequency of litigation was adjusted by the procedure frequency to determine which surgery has the greatest likelihood to be litigated relative to rotator cuff surgery.Forty-five cases were included in our study. After adjusting for the procedure frequency, the most likely procedure to be litigated, relative to rotator cuff repair, was manipulation under anesthesia (MUA), 251 times more likely to be litigated, and washout/lavage procedures, 17 times more likely to be litigated. Injection and total shoulder arthroplasty were 23 and 14 times less likely to be litigated relative to rotator cuff repair, respectively. In addition, the average age of the patients was 47 years, and 53% of the cases involved a male plaintiff. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement.This study identifies that MUA and lavage/washout procedures are much more likely to be litigated relative to rotator cuff repair. Rotator cuff repair is actually one of the least likely procedures to be litigated. Furthermore, settlement may represent a method of decreasing the indemnity paid for malpractice cases for which surgeons are implicated.

The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes.We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS.In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors.Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.

Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS).Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery.Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P 0.01) with either major bony (70% vs. 50%; P 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications.Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.

Within the geographic range of salmonid fishes, many apparently suitable rivers and streams are used for reproduction by some species but not others. This is widely known but seldom addressed, as studies often examine factors determining the distribution of one or only a few species. We examined physical factors associated with the spawning distribution of six native Pacific salmonids (pink, chum, coho, and Chinook salmon, bull trout, and steelhead) in the Skagit River basin, Washington. Annual mean temperature and catchment elevation had the strongest association with spawning assemblage distribution, but stream length, annual discharge, seasonal hydrology, and land use were also influential. Some species (e.g., pink and Chinook salmon) were more closely associated with each other and with common variables than others, and bull trout were the most distinctive. For interpretation, we investigated the roles of adult body size, timing of spawning, and duration of juvenile rearing, but none of these factors explained groupings in the data. Interspecific differences in habitat association remained, suggesting fundamental constraints on species distributions with implications for conservation and restoration.

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [ Orthopedics . 2023;46(3):e161–e166.]

Payer coverage policies have recently begun requiring physical therapy (PT) prior to total hip arthroplasty and total knee arthroplasty (TKA). It remains controversial if such a mandate is appropriate for patients with end-stage, symptomatic osteoarthritis. The purpose of this study is to assess if such patients are amenable to delaying surgery for a trial of PT.All patients scheduled for elective primary total hip arthroplasty and TKA in a 3-month period by 1 of 7 surgeons at a single institution were contacted and asked to participate in a survey. Participation in PT within the prior 6 months was noted. Patients were asked if they would be willing to delay surgery for a PT trial as a nonsurgical option to improve their symptoms. The primary reason for their answer was also recorded.In total, 200 patients were successfully contacted and agreed to participate. The mean age was 66 years, 47% were male, the mean body mass index was 31 kg/mPatients with end-stage hip and knee osteoarthritis who are otherwise candidates for surgery appear overwhelmingly opposed to mandatory preoperative PT, mostly due to a lack of perceived efficacy in providing long-term symptom relief compared to total joint arhtroplasty.

The shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient's specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study.Payment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square.A total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P.001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P.001.) CONCLUSION: Our results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.