Total shoulder arthroplasty using a subscapularis-sparing approach: a radiographic analysis.

BACKGROUND: Traditional total shoulder arthroplasty (TSA) involves releasing the subscapularis tendon for exposure. This can potentially lead to subscapularis insufficiency, compromised function, and dissatisfaction. A novel TSA technique preserves the subscapularis tendon by performing the procedure entirely through the rotator interval, allowing accelerated rehabilitation. However, early reports on this approach have noted malpositioning of the humeral component and residual osteophytes. In a randomized trial, we examined the incidence of humeral head malpositioning, incorrect sizing, and residual osteophytes on postoperative radiographs after subscapularis-sparing TSA compared with the traditional approach. METHODS: Patients were prospectively randomized to undergo TSA performed through the traditional or subscapularis-sparing approach. The operating surgeon was blinded to the randomization until the day of surgery. Anatomic reconstruction measurements included humeral head height, humeral head centering, humeral head medial offset, humeral head diameter (HHD), and head-neck angle. Two independent reviewers analyzed the postoperative radiographs to determine anatomic restoration of the humeral head and the presence of residual osteophytes. RESULTS: We randomized 96 patients to undergo either the standard approach (n = 50) or the subscapularis-sparing approach (n = 46). There were no significant differences in humeral head height, humeral head centering, humeral head medial offset, HHD, head-neck angle, and anatomic reconstruction index between the 2 groups. However, significantly more postoperative osteophytes (P = .0001) were noted in the subscapularis-sparing TSA group. Although the overall mean was not statistically different, further analysis of HHD showed that more patients in the subscapularis-sparing TSA group were outliers (mismatch >4 mm) than in the traditional TSA group. CONCLUSIONS: Although anatomic restoration of the shoulder can be accomplished using subscapularis-sparing TSA, retained osteophytes and significant mismatch of the HHD raise concerns regarding long-term outcomes.

Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care?

BACKGROUND: A systematic scan of the disparities intervention literature will allow researchers, providers, and policymakers to understand which interventions are being evaluated to improve minority health and which areas require further research. METHODS: We systematically categorized 391 disparities intervention articles published between 1979 and 2011, covering 11 diseases. We developed a taxonomy of disparities interventions using qualitative theme analysis. We identified the tactic, or what was done to intervene; the strategy, or a group of tactics with common characteristics; and the level, or who was targeted by the effort. RESULTS: The taxonomy included 44 tactics, 9 strategies, and 6 levels. Delivering education and training was the most common strategy (37%). Within education and training, the most common tactics were education about disease (14%) and self-management (11%), whereas communication skills training (3%) and decision-making aids (1%) were less frequent. The strategy of actively engaging the community through tactics such as community health workers and outreach efforts accounted for 6.5% of tactics. Interventions most commonly targeted patients (50%) and community members who were not established patients of the intervening organization (32%). Interventions targeting providers (7%), the microsystem (immediate care team) (9%), organizations (3%), and policies (0.1%) were less common. CONCLUSIONS: Disparities researchers have predominantly focused on the patient as the target for change; future research should also investigate how to improve the system that serves minority patients. Areas for further study include interventions that engage the community, educational interventions that address communication barriers, and the impact of policy reform on disparities in care.