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Abstract: The vice chair position in orthopaedic surgery departments has become increasingly prevalent over the last 10 years. Prior to this development, there were few, if any, vice chairs to support the chairperson position. The vice chair role has increased in importance as a result of increasing practice size and the increasing complexity of the health-care environment. The goal of this review was to summarize the current status of the vice chair position within orthopaedic surgery departments and to share the variety of vice chair roles that exist today., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article ( http://links.lww.com/JBJS/H884 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: Chewing, swallowing, and respiration are synchronized oropharyngeal functions. This study aimed to analyze the dynamics and coordination during natural chewing and swallowing in relation to respiratory phases., Design: Eight oropharyngeal muscles in minipigs were recorded using electromyography, X-ray fluoroscopy, and nasopharyngeal dynamics. Chewing cycles and swallowing episodes were analyzed for timing and activity amplitude along respiratory cycles. Digastric and middle pharyngeal constrictor were used as zero-points for timing analysis in chewing cycles and swallowing episodes, respectively. The beginning of these cycles and episodes were used as the zero-point for timing analysis in respiration during feeding., Results: The timing of jaw closing (57.8%) was longer than opening (42.2%) during chewing. Muscle activity occurred 20% later than digastric onsets and 15% earlier than jaw closing phase. Duration of muscle activity was shorter in ipsilateral than contralateral sides except for palatal muscles. Pharyngeal, palatal, and hyoid muscles showed longer durations than tongue muscles in jaw opening (p < 0.05). Palatal and hyoid muscles showed 2-phased activity in chewing while hyoid muscles showed higher amplitude in chewing and swallowing than other muscles. About 80% of the chewing cycles and swallowing episodes occurred in expiration. Nasopharyngeal airflow velocity increased from jaw opening to swallowing while airflow pressure decreased., Conclusion: These findings indicate key activity of palatal and pharyngeal muscles mostly in chewing. The respiratory cycle changes in chewing and swallowing simultaneously with the activation of the tongue, palatal, and pharyngeal muscles. These findings will be useful for further understanding the mechanisms in swallowing and breathing disorders., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest with the content of this article. Authors have no competing interests or other interests that might be perceived to influence the results and/or discussion reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Sleep quality, quantity, and efficiency have all been demonstrated to be adversely affected by rotator cuff pathology. Previous measures of assessing the impact of rotator cuff pathology on sleep have been largely subjective in nature. This study was undertaken to objectively analyze this relationship through the use of activity monitors., Methods: Patients with full-thickness rotator cuff tears at a single institution were prospectively enrolled between 2018 and 2020. Waistworn accelerometers were provided for the patients to use each night for 14 days. Sleep efficiency was calculated using the ratio of the time spent sleeping to the total amount of time that was spent in bed. Retraction of the rotator cuff tear was classified using the Patte staging system., Results: This study included 36 patients: 18 with Patte stage 1 disease, 14 with Patte stage 2 disease, and 4 patients with Patte stage 3 disease. During the study, 25 participants wore the monitor on multiple nights, and ultimately their data was used for the analysis. No difference in the median sleep efficiency was appreciated amongst these groups (P&gt;0.1), with each cohort of patients demonstrating a generally high sleep efficiency., Conclusions: The severity of retraction of the rotator cuff tear did not appear to correlate with changes in sleep efficiency for patients (P&gt;0.1). These findings can better inform providers on how to counsel their patients who present with complaints of poor sleep in the setting of full-thickness rotator cuff tears. Level of evidence: Level II.

Inflammatory, oxidative, and autoimmune responses cause severe damage to the nervous system inducing loss of myelin layers or demyelination. Even though demyelination is not considered a direct cause of skeletal muscle disease there is extensive damage in skeletal muscles following demyelination and impaired innervation. In vitro and in vivo evidence using exogenous antioxidants in models of demyelination is showing improvements in myelin formation alongside skeletal muscle recovery. For instance, exogenous antioxidants such as EGCG stimulate nerve structure maintenance, activation of glial cells, and reduction of oxidative stress. Consequently, this evidence is also showing structural and functional recovery of impaired skeletal muscles due to demyelination. Exogenous antioxidants mostly target inflammatory pathways and stimulate remyelinating mechanisms that seem to induce skeletal muscle regeneration. Therefore, the aim of this review is to describe recent evidence related to the molecular mechanisms in nerve and skeletal muscle regeneration induced by exogenous antioxidants. This will be relevant to identifying further targets to improve treatments of neuromuscular demyelinating diseases.

Background: Passive immunotherapy has been evaluated as a therapeutic alternative for patients with COVID-19 disease. Equine polyclonal immunotherapy for COVID-19 (EPIC) showed adequate safety and potential efficacy in a clinical trial setting and obtained emergency use authorization in Argentina. We studied its utility in a real world setting with a larger population., Methods: We conducted a retrospective cohort study at "Hospital de Campaña Escuela-Hogar" (HCEH) in Corrientes, Argentina, to assess safety and effectiveness of EPIC in hospitalized adults with severe COVID-19 pneumonia. Primary endpoints were 28-days all-cause mortality and safety. Mortality and improvement in modified WHO clinical scale at 14 and 21 days were secondary endpoints. Potential confounder adjustment was made by logistic regression weighted by the inverse of the probability of receiving the treatment (IPTW) and doubly robust approach., Findings: Subsequent clinical records of 446 non-exposed (Controls) and 395 exposed (EPIC) patients admitted between November 2020 and April 2021 were analyzed. Median age was 58 years and 56.8% were males. Mortality at 28 days was 15.7% (EPIC) vs. 21.5% (Control). After IPTW adjustment the OR was 0.66 (95% CI: 0.46-0.96) P = 0.03. The effect was more evident in the subgroup who received two EPIC doses (complete treatment, n = 379), OR 0.58 (95% CI 0.39 to 0.85) P = 0.005. Overall and serious adverse events were not significantly different between groups., Conclusions: In this retrospective cohort study, EPIC showed adequate safety and effectiveness in the treatment of hospitalized patients with severe SARS-CoV-2 disease., Competing Interests: DHFS, FA, AAG, NAO, SNMP, LSN, FC, OIMI declare reimbursement for conduction of the observational study as investigators. EN, GL, WHB, DHG and LP report personal fees from Inmunova. SG and BK declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Purpose: To evaluate the return-to-play rate and performance level changes in National Football League (NFL) athletes after a surgically treated pectoralis major muscle (PMM) tear. Methods: A descriptive epidemiologic study was conducted. All NFL players from 1933 to 2013 were reviewed for surgically treated PMM tears. Age at injury, height, weight, body mass index, date of injury, position played, draft selection, and total seasons played were recorded. Return to play was assessed for the entire cohort, as well as by position. Performance analysis before and after injury was also conducted for the entire cohort, as well as by position and draft selection. Data analysis was performed with the paired-samples t test, with P < .05 considered statistically significant. Results: Our review of 80 NFL seasons from 1933 to 2013 provided a total of 55 instances of PMM tears. All instances occurred between the time frame of 2004 and 2012. After exclusions, 24 instances unique to 24 NFL athletes were confirmed by 2 separate investigators and these athletes were included as our final study cohort. Of the 24 players identified to have a surgically repaired PMM tear, 20 (83%) returned to play. The mean return-to-play period was 302 ± 128 days. The mean difference in performance scores before versus after PMM injury was 171.33 and was statistically significant, with P  = .0330. Conclusions: In this study, there was an 83% return-to-play rate after surgical repair of PMM tears. Although we found a statistically significant decrease in player performance after surgery, this difference was no longer seen after players were stratified by position type and draft selection. Level of Evidence: Level IV, therapeutic case series., (© 2022 The Authors.)

Background: Recurrent shoulder instability after reverse total shoulder arthroplasty (rTSA) presents a challenging clinical problem. A handful of cases have been reported describing stability achieved only after revision rTSA with cerclage augmentation. We describe an acromiohumeral cerclage technique, where the humeral component is fixed with a nonabsorbable, high-tensile suture tape looped through transosseous acromial drill tunnels as an augment to salvage shoulder stability., Methods: All patients treated with acromiohumeral cerclage in rTSA for instability between November 1, 2015, and February 1, 2020, with minimum 1-year follow-up were included. Demographic information, baseline preoperative and postoperative range of motion at most recent follow-up, American Shoulder and Elbow Surgeons (ASES) shoulder scores, and visual analog scale (VAS) scores were recorded and compared., Results: Ten patients, 4 female and 6 male, aged 64.3 ± 7.4 years (range, 53-77 years) with the mean postoperative follow-up of 23 months were included; 90% underwent surgery on the dominant side. Patients underwent an average of 2.1 ± 1.9 prior revisions (range, 0-7), over an average of 10.4 months (range, 0-72 months), before revision with suture cerclage augmentation was performed. All patients either had significant past shoulder history at other institutions and/or comorbidities that added significant complexity to their cases, with an average of 0.6 ± 0.9 (range, 0-3) prior other shoulder operations performed before their initial rTSA. The average decrease in VAS score among the 10 patients was 4.3 ± 2.7 (P < .05), ranging from 0 to 8 points. The average increase in ASES score was 51.3 ± 21 (P < .05), ranging from 13.3 to 69.9 points. The average increase in active forward elevation for 8 patients was 79° ± 39° (P = .0008), ranging from 40° to 160°. All patients have remained stable with well-positioned prostheses since their final operations with no recurrent dislocations or acromial complications. Two patients unable to travel for an office visit were contacted via phone and answered questions to obtain postoperative ASES and VAS scores., Conclusion: Acromiohumeral cerclage suture augmentation in revision rTSA may be a useful, simple surgical strategy to employ with other revision and augmentation techniques to treat cases of recurrent, chronic instability, particularly in the setting of multiple revisions., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: To describe the proportional anatomic relationship of the long head of the biceps tendon (LHBT) myotendinous junction (MTJ) to pectoralis major tendon (PMT) and to provide an up-to-date review of the current literature., Methods: Ten fresh frozen cadaveric specimens were used. A deltopectoral approach was used for exposure and anatomical location of the MTJ as well as the proximal and distal borders of the PMT were identified by 2 fellowship-trained shoulder and elbow surgeons. The longitudinal length of the PMT, the distance from the long head of the biceps (LHB) MTJ to the proximal border of the PMT (pMTJ), and the distance from the LHB MTJ to the distal border of the PMT (dMTJ) were recorded. The relationship between the pMTJ and the PMT length was then reported as a ratio., Results: The PMT was found to have a length of 5.16 ± 0.64 cm (4.1-6.1 cm). The pMTJ was 1.14 ± 0.52 cm (0.5-1.9 cm), and the dMTJ was 4.02 ± 0.91 cm (2.5-5.3 cm). The pMTJ/PMT ratio was 0.23 ± 0.11 (0.10-0.39)., Conclusions: We found the average length of the PMT footprint to be 5.16 cm with the LHB MTJ beginning 1.14 cm distal to its proximal border., Clinical Relevance: It is important to understand the LHBT and its relationship to surgically relevant surrounding anatomy to allow for appropriate tensioning and improved patient outcomes in the treatment of LHBT shoulder pathology., (© 2022 The Authors.)

In skeletal muscles, niche factors stimulate satellite cells to activate and induce muscle regeneration after injury. In vitro, matrigel is widely used for myoblast differentiation, however, is unsuitable for clinical applications. Therefore, this study aimed to analyze attachment and differentiation of satellite cells into myotubes on fibrin coatings with selected niche components. The attachment of satellite cells to fibrin alone and fibrin with niche components (laminin, collagen-IV, laminin-entactin complex [LEC]) were compared to matrigel. Only on matrigel and fibrin with LEC, Pax7-positive cells attached well. Then, LEC was selected to analyze proliferation, differentiation, and fusion indices. The proliferation index at day 1 on fibrin-LEC (22.5%, SD 9.1%) was similar to that on matrigel (30.8% [SD 11.1%]). The differentiation index on fibrin-LEC (28.7% [SD 6.1%] at day 5 and 32.8% [SD 6.7%] at day 7) was similar to that on matrigel (40.1% [5.1%] at day 5 and 27.1% [SD 4.3%] at day 7). On fibrin-LEC, the fusion index at day 9 (26.9% [SD 11.5%]) was similar to that on matrigel (25.5% [SD 4.7%]). Our results showed that the addition of LEC enhances the formation of myotubes on fibrin. Fibrin with LEC might be suitable to enhance muscle regeneration after surgery such as cleft palate repair and other muscle defects., (© 2022 The Authors. European Journal of Oral Sciences published by John Wiley & Sons Ltd on behalf of Scandinavian Division of the International Association for Dental Research.)

Background: Health care disparities have been well-documented in literature to affect care and recovery after surgery. Insurance type is regularly cited by orthopedic surgeons to play a role in the incongruences faced by patients in the perioperative period. Recent trends highlight an increased reluctance by some insurance companies to approve indicated surgery. Our primary objective was to assess insurance type and how it affects approval rates for rotator cuff débridement and rotator cuff repair., Methods: A retrospective review of 999 patients who underwent arthroscopic rotator cuff débridement or repair was conducted. Data abstraction included demographics, prior surgical or nonsurgical interventions, radiologic imaging, insurance type, and denial of insurance coverage. Patients were grouped by insurance type-Medicaid, Medicare, workers' compensation, and private insurance. Univariable and multivariable logistic regression models were developed to estimate odds ratios (ORs) for insurance type associated with the denial of insurance coverage., Results: Nine hundred ninety-seven patients were included in our final analysis. Those with private insurance were more likely to be non-Hispanic white (71%), whereas the proportion of Hispanics was highest among those with workers' compensation (27%) and Medicaid (20%). There were no significant differences by insurance type for prior nonsurgical interventions and radiologic imaging. For previous surgical interventions (13%), however, rates were higher for Medicaid (18%) and workers' compensation (17%) than those for Medicare (12%) and private insurance (9%) ( P  = .003). Compared with private insurance, the odds of insurance denial were significantly higher for those with Medicaid at 54% (OR: 7.91, 95% confidence interval: 5.27-11.88, P  < .001) and workers' compensation at 19% (OR: 1.71, 95% confidence interval: 1.04-2.81, P  = .04)., Discussion: One in 2 patients with Medicaid coverage faces insurance denial compared with any other insurance type. Workers' compensation follows with the second highest rates. Almost half the Hispanic population are insured by either Medicaid or workers' compensation and may face barriers to care that can negatively impact outcomes and complication rates.

Background: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables., Questions/purposes: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?, Methods: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics., Results: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did., Conclusion: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases., Clinical Relevance: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic., Competing Interests: This study received funding from NCATS/NIH (award number UL1TR000445). Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

This study aimed to analyze the effects of fibrin constructs enhanced with laminin-nidogen, implanted in the wounded rat soft palate. Fibrin constructs with and without laminin-nidogen were implanted in 1 mm excisional wounds in the soft palate of 9-week-old rats and compared with the wounded soft palate without implantation. Collagen deposition and myofiber formation were analyzed at days 3, 7, 28 and 56 after wounding by histochemistry. In addition, immune staining was performed for a-smooth muscle actin (a-SMA), myosin heavy chain (MyHC) and paired homeobox protein 7 (Pax7). At day 56, collagen areas were smaller in both implant groups (31.25 ± 7.73% fibrin only and 21.11 ± 6.06% fibrin with laminin-nidogen)) compared to the empty wounds (38.25 ± 8.89%, p < 0.05). Moreover, the collagen area in the fibrin with laminin-nidogen group was smaller than in the fibrin only group ( p ˂ 0.05). The areas of myofiber formation in the fibrin only group (31.77 ± 10.81%) and fibrin with laminin-nidogen group (43.13 ± 10.39%) were larger than in the empty wounds (28.10 ± 11.68%, p ˂ 0.05). Fibrin-based constructs with laminin-nidogen reduce fibrosis and improve muscle regeneration in the wounded soft palate. This is a promising strategy to enhance cleft soft palate repair and other severe muscle injuries.

Objective: The aim of this study was to analyze the function of the palatal muscles in vivo by real-time wireless electromyography in rats. The effects of palatal wounding were also analyzed., Methods: Microelectrodes were implanted six rats; in the masseter muscle (two-rats) for comparison, in the unwounded soft palate (two-rats) and the soft palate that received a surgical wound (two-rats). Two weeks after implantation, a wound was made in the soft palate using a 1 mm biopsy-punch. Electromyographic measurements and video-recordings were taken weekly to monitor train-duration and peak-amplitude during eating, grooming and drinking., Results: The train-duration of the masseter muscle during eating was 0.49 ± 0.11 s (rat-1) and 0.56 ± 0.09 s (rat-2), which was higher than during grooming. In the unwounded soft palate the train-duration during eating was 0.63 ± 0.12 s (rat-1) and 0.69 ± 0.069 s (rat-2), which was higher than during grooming and drinking. The peak-amplitude for eating in the normal soft palate before surgery was 0.31 ± 0.001 mV (rat-1) and 0.33 ± 0.02 mV (rat-2). This decreased to 0.23 ± 0.03 mV and 0.25 ± 0.11 mV respectively, after surgery. For drinking the peak-amplitude was 0.30 ± 0.01 mV (rat-1) and 0.39 ± 0.01 mV (rat-2) before surgery, which decreased to 0.23 ± 0.09 mV and 0.20 ± 0.14 mV respectively, after surgery., Conclusion: The reduced peak-amplitude suggests impaired soft palate function after wounding. This is the first study into the in vivo function of the soft palate after surgical wounding. This model will contribute to develop strategies to improve soft palate function in patients., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Devastating transient and permanent postoperative neurocognitive complications in previously healthy, low-risk patients have been observed after elective shoulder arthroscopy in the beach chair position (BCP). Continuous monitoring of cerebral oxygen saturation has been recommended to identify cerebral desaturation events (CDEs) and improve patient safety. However, the relatively high cost and limited availability of monitoring may not be cost-effective. More cost-effective and available measures, including the use of thigh-high compression stockings (CS), have been investigated. However, efficacy data of CS usage is limited, especially for obese patients, who have been shown to be at increased risk for CDEs. The purpose of this was study was to determine if the intraoperative addition of thigh-high compression stockings decreases the incidence, frequency, and magnitude of CDEs in obese patients undergoing shoulder arthroscopy in the BCP., Methods: Thirty-three patients in the treatment group wore both thigh-high compression stockings (CS) and sequential compression devices (SCDs), and the remaining 33 patients in the control group wore SCDs alone. Cerebral oximetry was monitored during surgery using near-infrared spectroscopy., Results: The incidence of CDEs was equal between groups, with 9 patients (27%) in each experiencing desaturation events. The median number of CDEs per patient was 3 for the control group and 1 for patients wearing CS (P = .29). There was no difference between groups in terms of median time from induction of anesthesia to onset of CDE (P = .79), median time from upright positioning to onset of CDE (P = .60), mean CDE duration per patient (P = .22), and median cumulative CDE duration (P = .19). The median maximal desaturation from baseline was also not different between groups: 27.6% in the control group and 24.3% in the treatment group (P = .35)., Conclusion: The combination of thigh-high CS and SCDs did not decrease the incidence, frequency, or magnitude of CDEs in patients undergoing shoulder arthroscopy in the BCP. Twenty-seven percent of patients undergoing shoulder arthroscopy in the BCP demonstrated CDEs with or without the use of CS. Therefore, further research is required to identify cost-effective, minimally invasive, and universally available methods of decreasing the incidence of CDEs during this common surgical procedure., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: No previous data have demonstrated the effect of manual pressure during cement curing on interference-fit glenoid implant fixation in total shoulder arthroplasty. In this study, we examined cement mantle characteristics and implant seating using two different methods of securing an interference-fit glenoid implant with peripheral cemented pegs: a manual pressure technique versus a pressureless technique., Methods: Sixteen cadaveric scapulae were harvested, and their glenoids were prepared for component insertion. Glenoids with an interference-fit central peg were cemented into the peripheral holes and fully seated. Two techniques were employed during cement curing: (1) a manual pressure technique (8 glenoids), which used a static 70 N load application to each implant for 10 minutes; and (2) a pressureless technique (8 glenoids), which used no pressure application, and the implant was left to set without intervention. Each glenoid was subsequently imaged using microcomputed tomography and analyzed for differences in cement mantle characteristics and implant seating., Results: The mean area of cement penetration for the manual pressure technique was not statistically different from the pressureless group (P = .26, valid N = 288). The average implant incongruity after final seating in the manual pressure group was 0.63 mm, compared with 1.0 mm in the pressureless group. A linear mixed effects model with a Kenward-Roger correction was used to compare the two groups, and no significant difference was found (Mdiff = -0.386, 95% confidence interval: -0.978 to 0.206; P = 0.17)., Conclusion: Manual pressure of the glenoid component during cement curing yielded no difference in the cement mantle area or final implant seating incongruity compared with a pressureless technique. This knowledge could potentially benefit both the surgeon and the patient by increasing the efficiency in total shoulder arthroplasty surgery.

Background: Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates where iliosacral screws may be placed when stabilizing pelvic ring injuries. In dysmorphic sacra, the safe osseous corridor of the upper sacral segment (S1) is smaller and lacks a transsacral corridor, increasing the need for fixation in the second sacral segment (S2). Previous evidence suggests that S2 is less dense than S1. The aim of this cross-sectional study is to further evaluate bone mineral density (BMD) of the S1 and S2 iliosacral osseous pathways through morphology stratification into normal and dysmorphic sacra., Materials and Methods: Pelvic computed tomography scans of 50 consecutive trauma patients, aged 18 to 50 years, from a level 1 trauma center were analyzed prospectively. Five radiographic features (upper sacral segment not recessed in the pelvis, mammillary bodies, acute alar slope, residual S1 disk, and misshapen sacral foramen) were used to identify dysmorphic characteristics, and sacra with four or five features were classified as dysmorphic. Hounsfield unit values were used to estimate the regional BMD of S1 and S2. Student's t-test was utilized to compare the mean values at each segment, with statistical significance being set at p < 0.05. No change in clinical management occurred as a result of inclusion in this study., Results: A statistical difference in BMD was appreciated between S1 and S2 in both normal and dysmorphic sacra (p < 0.0001), with 28.4% lower density in S2 than S1. Further, S1 in dysmorphic sacra tended to be 4% less dense than S1 in normal sacra (p = 0.047). No difference in density was appreciated at S2 based on morphology., Conclusions: Our results would indicate that, based on BMD alone, fixation should be maximized in S1 prior to fixation in S2. In cases where S2 fixation is required, we recommend that transsacral fixation should be strongly considered if possible to bypass the S2 body and achieve fixation in the cortical bone of the ilium and sacrum., Level of Evidence: Level III.

Orofacial congenital defects such as cleft lip and/or palate are associated with impaired muscle regeneration and fibrosis after surgery. Also, other orofacial reconstructions or trauma may end up in defective muscle regeneration and fibrosis. The aim of this review is to discuss current knowledge on the development and regeneration of orofacial muscles in comparison to trunk and limb muscles. The orofacial muscles include the tongue muscles and the branchiomeric muscles in the lower face. Their main functions are chewing, swallowing, and speech. All orofacial muscles originate from the mesoderm of the pharyngeal arches under the control of cranial neural crest cells. Research in vertebrate models indicates that the molecular regulation of orofacial muscle development is different from that of trunk and limb muscles. In addition, the regenerative ability of orofacial muscles is lower, and they develop more fibrosis than other skeletal muscles. Therefore, specific approaches need to be developed to stimulate orofacial muscle regeneration. Regeneration may be stimulated by growth factors such fibroblast growth factors and hepatocyte growth factor, while fibrosis may be reduced by targeting the transforming growth factor β1 (TGFβ1)/myofibroblast axis. New approaches that combine these 2 aspects will improve the surgical treatment of orofacial muscle defects.

Because of the ever increasing economic, social, legal, and regulatory complexities of the current healthcare environment, traditional clinical training may be insufficient to establish a thriving surgical practice and to achieve individual career goals. Competing constituencies and agendas require thoughtful strategies to achieve professional goals. An orthopaedic surgeon's formal professional education, research experience, and clinical expertise may not fully equip individuals for success in the contemporary healthcare market. With the pressures of modern surgical practices, formal and informal senior mentorship may be critically important, especially for young orthopaedic surgeons. The role of mentorship in job satisfaction, retention, clinical productivity, and research output has been recently investigated across multiple medical and surgical disciplines. These data support the theory that senior mentorship is critical for retention, job satisfaction, clinical volume, professional networking, career progression, and research productivity.

Case: A 22-year-old woman with Ehlers-Danlos syndrome (EDS) presented with profound elbow instability. A surgical technique that combined medial and lateral ligament reconstruction with the application of a temporary hinged internal fixator was performed. At 1 year postsurgery, the elbow remains stable and asymptomatic and has an excellent range of motion., Conclusion: Elbow instability due to EDS is a rare but disabling condition, especially in young active patients. Treatment of recurrent elbow instability with collateral ligament reconstruction and a temporary hinged internal fixator may be a viable surgical option to achieve stability, restore function, and preserve quality of life.

Introduction: The purpose of our study is to compare pectoralis major tears in active duty military personal repaired surgically in the forward deployed setting to those performed in the Continental United States., Materials and Methods: Retrospective comparison of all pectoralis major tendon repairs performed at Madigan Army Medical Center from 2000 to 2007 to a forward deployed series treated by two deployed United States Air Force orthopedic surgeons at one expeditionary medical treatment facility over a 4-month deployment cycle from December 2013 through March 2014., Results: Fourteen patients from the CONUS group and eight patients from deployed group were compared; they had a mean age of 32 years (21-52) all with pectoralis major ruptures that underwent operative fixation. Nineteen of the 22 patients (86%) sustained their injuries during bench press. The average bench press weight was similar with 271.8 lbs in the CONUS group and 273.1 lbs in the deployed group. There were 9 complete tears and 5 partial tears in the CONUS cohort whereas 7 complete tears and 1 partial tear in the deployed cohort, with all tears in both groups occurring at the insertion of the humerus. All 22 patients in both cohorts denied the use of anabolic steroids. The average DASH score at final follow-up was 12.74 in the CONUS group and 36.44 in the deployed group. The CONUS group reported that 7 out of 8 immediate repair patients and 4 out of 6 delayed repair patients returned to functional work level within 6 months with the 2 patients in the delayed repair group taking longer than 9 months to return to work. The deployed members reported return to functional work level at an average of 6.5 months. Both cohorts had early return to weight lifting at 6 and 7 months, respectively. The CONUS group reported a 39% bench press weight reduction and 34% pushup maximum reduction whereas the deployed cohort reported a 20% and 8% reduction respectively., Conclusions: When comparing deployed to CONUS results, we demonstrated that surgical repairs at one permanent US military in-theater tertiary referral medical center were as successful as repairs performed at one CONUS US Army academic tertiary referral medical center. Although in-theater surgical repair was technically feasible and clinically successful, we believe the lengthy convalescence, stringent post-operative restrictions, demanding environment and impact on operational readiness should preclude deployed surgical repairs from becoming standard practice., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

The beach chair position (BCP) is commonly used position in upper extremity surgery. Although there are many advantages to surgery in this position, there are also potential drawbacks and described complications including devastating neurologic outcomes. The etiology of these complications is postulated to be due to the gravitational effects of the seated position leading to cerebral hypoperfusion. We review the current literature on intraoperative cerebral monitoring and neurocognitive complications with shoulder surgery performed in the BCP. A previous systematic review estimated the incidence of neurocognitive complications after surgery in the BCP to be 0.004%. However, the true incidence is unknown and is likely much more common. Reports of neurologic complications have revealed a need for heightened vigilance, alternative anesthesia techniques, and improved monitoring. Methods for monitoring have included near-infrared spectroscopy, a measurement of cerebral oximetry shown to reliably detect cerebral hypoperfusion. In this literature review, we sought to update the incidence of intraoperative cerebral desaturation events (CDEs) to investigate the relationship of CDEs to neurocognitive complications and to review recent reported cases of neurocognitive complications. Existing literature suggest that accurate intraoperative monitoring of cerebral perfusion may improve patient safety., (Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Given the increase in the incidence and survivability of those with solid organ transplantations in the United States, the purpose of this study was to identify inpatient, 30-day, and 90-day outcomes following primary shoulder arthroplasty in transplant recipients. The Healthcare Cost and Utilization Project State Inpatient Databases identified patients who underwent shoulder arthroplasty after solid organ transplantation between January 2007 and December 2013. International Classification of Diseases, Ninth Revision, codes were used to define the primary composite outcome of death or postoperative complication. Logistic models with frequency weights were used to compare propensity-matched groups. Patients undergoing primary shoulder arthroplasty following solid organ transplant are at elevated risk of inpatient and 30-day and 90-day postoperative complications (respiratory, hemorrhage) and have longer length of stays compared with nontransplant patients. Transplant patients did not have an increased risk of surgical site infection or mortality at any time point (Journal of Surgical Orthopaedic Advances 28(1):41-47, 2019).

Background: Humeral bone loss is commonly encountered during revision shoulder arthroplasty and anticipating humeral bone defects can help the revision surgeon make appropriate plans to achieve adequate fixation and stability. No validated classification system exists to characterize humeral bone loss in the setting of revision shoulder arthroplasty., Questions/purposes: The purposes of this study were (1) to create a classification system for humeral bone loss in revision shoulder arthroplasty; (2) to determine the classification system's reliability; and (3) to determine whether humeral bone loss type is associated with intraoperative humeral-related reconstruction characteristics., Methods: This was a comparative retrospective radiographic study. First, six surgeons from five centers collaborated to create a classification by consensus. Second, two surgeons from two other centers who had fellowship training in shoulder and elbow surgery, who were blinded to each other's grades and all patient details other than plain radiographs, and who were not involved in creation of the system, classified true AP, AP, and lateral (axillary and/or scapular-Y) radiographs from 108 revision (413 radiographs) from one center that were performed between November 15, 2006, and January 4, 2018. Interobserver reliability was calculated by comparing those two reviews and determining Cohen's κ. In addition, one reviewer repeated his assessments twice, 4 months apart, to determine intraobserver reliability using Cohen's κ. Third, we performed a retrospective chart study of these same revisions to determine intraoperative humeral-related reconstruction characteristics such as the use of greater tuberosity fixation, stem length, humeral bone grafting, and the use of proximal humeral replacement or total humeral replacement; at the center where these revisions were performed during that timespan, no attempt to classify bone loss was made. During that period, the general indications for greater tuberosity fixation included the absence of a stable osseous connection between the greater tuberosity and the shaft of the humerus with a tuberosity amendable to repair; the general indications for use of longer stems were inability to obtain a minimum of two cortical widths of overlap between the implant and the humeral diaphysis and/or loss of the greater tuberosity; and the general indications for proximal and total humeral replacement were bone loss that was felt to be too severe to allow reconstruction with allograft., Results: The classification system consists of three types of humeral bone loss: Type 1 is loss of the epiphysis with subtypes for loss of the calcar and loss of the greater tuberosity; Type 2 is loss of the metadiaphysis above the deltoid attachment with a subtype for cortical thinning; and Type 3 is bone loss extending below the deltoid attachment with a subtype for cortical thinning. We studied 108 revisions: 38 (35%) without bone loss, 34 (31%) Type 1, 27 (25%) Type 2, and nine (8%) Type 3. For reliability, interrater κ was 0.545 and in 71% (77 of 108) of revisions, the two raters agreed on a numeric type. Intrarater κ was 0.615 and in 77% (83 of 108) of revisions, the rater agreed with himself as to the numeric type. Stem length increased with class type (Type 1 median [range] 130 [70-210], Type 2 150 [70-210], Type 3 190 [70-240], p = 0.005). Most greater tuberosity fixation for intraoperative fracture was in Types 1 and 2 (13 of 18 compared with the five of 18 of greater tuberosity fixation that was within Types 0 and 3, p = 0.043). Most bone grafting was in Types 2 and 3 (eight of 13 compared with five of 13 of bone grafting was in Types 0 and 1, p = 0.044). Most proximal humeral and total humeral replacements were in Type 3 (three of four compared with one of four, p < 0.001)., Conclusions: We developed the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) system, which has adequate, if imperfect, reliability to classify humeral bone loss in the setting of revision shoulder arthroplasty. This classification system may be useful to anticipate the complexity of humeral reconstruction. Further validation incorporating advanced imaging and further evaluators will be necessary., Level of Evidence: Level III, diagnostic study.

Introduction: The purpose of this study was to determine how reverse and total shoulder arthroplasty (RTSA and TSA) comparative utilization, postoperative diagnoses, demographics, and perioperative data have changed between 2005 and 2015., Methods: This was a single-center retrospective review of all primary TSAs and RTSAs., Results: Our cohort included 1,192 RTSAs and 1,600 TSAs. Although both RTSA and TSA volume increased, RTSA increased from 27% to 52% of shoulder arthroplasty. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased. The mean age decreased for RTSA and TSA, and American Society of Anesthesiologists scores increased for both., Discussion: Over the past decade, RTSA has become the most common primary shoulder arthroplasty, reflecting the clinical success of the procedure. This increase is due to both an increase in the number of RTSAs performed for rotator cuff tear arthropathy as well as expanding surgical indications for RTSA., Level of Evidence: Retrospective, level IV.

There is a growing consensus that an accomplished curriculum vitae and prior achievement as an academician may not correlate with success as a chairperson of a contemporary academic orthopaedic department. As surgeons, formal professional education, research expertise, and clinical experience often are inadequate to foster the necessary skills and experience in executive leadership, change management, business administration, and strategy. The recruiting and hiring processes to fill academic leadership roles have been slow to adapt and recognize the skills that are necessary to be a successful chairperson. Recent research has identified emotional competency, resiliency, leadership, communication, results orientation, and personnel development as skills that correlate with success in academic leadership. Formal courses and training in executive leadership and business management may be helpful in enhancing knowledge and skills in these disciplines.

Health-care reform, market competition, cost containment, and pressure for productivity have dramatically impacted the practice of orthopaedic surgery and academic surgical training. Orthopaedic leaders and training programs are striving to identify and solve these contemporary challenges. Herein, we focus on 4 areas that currently pose important challenges to modern orthopaedic surgical departments and academic hospital systems, including the demanding and evolving skill sets that are required of physician leaders, the effects of the changing medical-legal environment on academic medicine, the impact of increased clinical productivity emphasis on surgical education, and departmental leadership transitions.

Although peripheral nerve injury may result from fractures involving the long bones, bony entrapment of peripheral nerves is infrequently encountered. This report demonstrates a rare case of superficial peroneal nerve entrapment between 2 fracture ends of the distal fibula following a closed ankle fracture resulting from a supination-external rotation mechanism., Levels of Evidence: Therapeutic, Level IV: Case report.

Background: Very little longitudinal information has been available regarding the relationship of cuff tears and arthritis. The purpose of this study was to determine the midterm risk of and risk factors for rotator cuff tear arthropathy progression in a cohort of subjects with an asymptomatic rotator cuff tear., Methods: Baseline (visit 1), 5-year (visit 2), and most recent follow-up (visit 3) radiographs were reviewed in a cohort of 105 subjects enrolled for longitudinal surveillance of asymptomatic degenerative rotator cuff tears and 33 controls. The radiographs were assessed in a blinded, randomized fashion by 3 observers who graded glenohumeral arthritic changes using the Hamada scores, Samilson-Prieto (SPO) scores, and acromiohumeral interval (AHI)., Results: Osteoarthritis (SPO classification), cuff tear arthropathy (Hamada classification), and AHI progressed between visits 1 and 3 (median, 8 years; P < .001 in all cases). SPO progression was not significantly different for partial- vs. full-thickness vs. control baseline tear types (P = .19). Both full-thickness and partial-thickness tears had greater progression in Hamada scores than controls did in the first 5 years of follow-up (P = .02 and P = .03, respectively), but scores did not differ between partial- and full-thickness tears. Tears with and without enlargement did not differ in progression in SPO grade, Hamada grade, or AHI., Conclusions: Glenohumeral arthritic changes progress significantly but remain minimal within an 8-year period in early to moderate degenerative cuff disease. Whereas the presence of a rotator cuff tear influences progression in Hamada grade, the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The cartilage and bone metaplasia occurring in both the heart and blood vessels, are the result of risk factors or chronic diseases that gradually adversely affect the performance of a person in society; however, clinical signs are reversible in early and intermediate stages of alterations., Objective: To establish how the molecular mechanisms underlying the increased vascular metaplastic changes and possible aspects of treatment and prevention., Materials and Methods: A systematic review was performed by searching for articles indexed in PubMed, Scopus and Science Direct data from 1995 to 2015. The MeSH descriptors used were metaplasia and vascular calcification, which terms associated were molecular mechanisms, condrogenic and osteogenic., Results and Discussion: Multiple factors influence the metaplastic change, especially the pro-inflammatory associated with vascular oxidation and the presence of free radicals; this development is reversible by treatment with antioxidants and changes in lifestyle and secondary prevention as there is a diagnosis of chronic degenerative disease., Conclusion: The literature evidences that factors that reduce the tissue oxidative stress and promote the maintenance of vascular phenotype are protective and / or reducing the osteochondral metaplastic formations.

Tailor-made additives, which are molecules that share the same molecular structure as a parent molecule with only slight structural variations, have previously been demonstrated as a useful means to control crystallization dynamics in solution. For example, tailor-made additives can be added to solutions of a crystallizing parent molecule to alter the crystal growth rate, size, and shape. We apply this strategy as a means to predictably control morphology in molecular bulk-heterojunction (BHJ) photovoltaic cells. Through the use of an asymmetric oligomer substituted with a bulky triisobutylsilyl end group, the morphology of BHJ blends can be controlled resulting in a near doubling (from 1.3 to 2.2%) in power conversion efficiency. The use of tailor-made additives provides promising opportunities for controlling crystallization dynamics, and thereby film morphologies, for many organic electronic devices such as photovoltaics and field-effect transistors.