Stemless Reverse Shoulder Arthroplasty.

Since the Food and Drug Administration (FDA) approval nearly two decades ago, the indications for and utilization of reverse shoulder arthroplasty (RSA) have expanded considerably. Stemless RSA designs have been used in Europe since 2005, but have only recently been introduced in domestic Investigational Device Exemption trials. Potential advantages of stemless RSA are similar to those of stemless anatomic total shoulder arthroplasty, which may include fewer shaft-related complications, avoidance of stress shielding, bone preservation, and easier revision surgery. European data support similar outcomes between certain stemless RSA prostheses compared with that of stemmed RSA implants at early and mid-term follow-up. However, long-term outcomes remain to be seen and differences exist between the stemless RSA designs used in Europe and those being studied in domestic clinical trials. An understanding of the potential advantages and disadvantages of stemless RSA, differences between existing designs, and reported clinical outcomes is prudent for the safe and meaningful implementation of this new technology in the United States.

Pediatric Forearm Muscle Herniation Treated With an Acellular Dermal Allograft.

Muscle herniations occur through acquired fascial defects in the lower extremities; upper-extremity herniations are rare. The affected patients are typically adult men engaging in strenuous exercise or with injury; pediatric cases are infrequent. We a pediatric patient with a symptomatic, forearm herniation treated with fascial defect closure using an acellular dermal allograft. This case report highlights not only the presence of this rare condition in pediatrics but also a safe and viable treatment option for this patient population. The patient presented with pain and soft-tissue swelling of the forearm, was diagnosed with muscular herniation, and was surgically treated with fascial defect closure using an acellular dermal allograft. All symptoms resolved, without the recurrence of herniation and with return to sport. Upper-extremity muscle herniations are rare but should be considered in pediatric patients following trauma/surgery and can be treated successfully with acellular dermal allografts.

An Analysis of Component Positioning, Offset, and Limb Length Restoration in Computer-Assisted Hip Resurfacing Arthroplasty.

INTRODUCTION: Hip resurfacing arthroplasty (HRA) is a surgical option with positive outcomes at medium-term follow-up for young, active patients with osteoarthritis. However, early failures of HRA often occur due to improper implant placement. The purpose of this study was to assess the utility of computer-assisted navigation in the effort to optimize implant positioning following HRA. MATERIALS AND METHODS: A retrospective analysis of 262 consecutive HRAs at a single institution was performed. Radiographic analysis included measurements of cup inclination and anteversion, leg length restoration (LLR), and offset. Cup position was evaluated based on placement within Lewinnek parameters and the surgeon's preferred anteversion (10° to 20°). Chi-squared and unpaired Student's t-test were performed for all categorical and continuous variables, respectively. RESULTS: One hundred fifty-six cases were performed using conventional technique and 106 cases used computernavigation. Computer-assisted HRA (caHRA) had a longer mean surgical time (129 vs. 110 minutes; p < 0.001) but shorter average LOS (1.1 vs. 1.5 days; p < 0.001). Cup position was within the surgeon-preferred target zone in 47% of caHRA versus 22% of conventional HRA (p = 0.0001). Cup position fell within the Lewinnek safe zone in 86% of caHRA versus 60% of conventional HRA (p < 0.001). Global offset was reduced by a mean of 6.4 mm in caHRA versus 8.4 mm (p = 0.036). No differences in rates of complication (p = 0.406), reoperation (p = 1.00), or 90-day readmission (p = 0.568) were observed. CONCLUSION: Computer-assisted technology in HRA allows for comparable clinical outcomes to conventional technique. Cup position accuracy and precision is improved by computer navigation in HRA.

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis.

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Work-related outcomes of revision rotator cuff repair for patients receiving workers' compensation.

BACKGROUND: Workers' compensation (WC) patients are susceptible to poorer outcomes following primary rotator cuff repair (RCR). Failure of structural healing can explain some poor results, and outcomes of revision RCR in this population are unknown. METHODS: A retrospective review was performed of individuals receiving WC who underwent arthroscopic revision RCR with or without dermal allograft augmentation at a single institution between January 2010 and April 2021. Preoperative magnetic resonance imaging (MRI) scans were assessed for rotator cuff tear characteristics, Sugaya classification, and Goutallier grade. Postoperative imaging was not routinely obtained unless for continued symptoms or reinjury. Primary outcome measures included return-to-work status, reoperation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) scores. RESULTS: Twenty-seven shoulders (25 patients) were included. The population was 84% male, with a mean age of 54 years; 67% were manual laborers, 11% sedentary workers, and 22% with a mixed profession. Average follow-up was 35.4 months. Fifteen patients (56%) returned to work at full-duty status. Six (22%) returned to work with permanent restrictions. Six (22%) were unable to return to work in any capacity. Thirty percent of all patients and 35% of manual laborers changed occupation following revision RCR. Mean time to return to work was 6.7 months. Overall, symptomatic rotator cuff retear was found in 13 patients (48%). Reoperation rate after revision RCR was 37% (10 cases). Among patients who did not undergo reoperation, mean ASES scores improved from 37.8 to 69.4 at final follow-up (P < .001). Mean SANE scores only improved marginally from 51.6 to 57.0 (P = .61). No statistically significant correlation was found between preoperative MRI findings and outcome measures. CONCLUSION: Workers' compensation patients demonstrated fair improvements in outcome scores after revision RCR. Although some patients are able to return to full duty, nearly half were either unable to return or returned with permanent restrictions. These data are helpful for surgeons when counseling patients about expectations and return to work after revision RCR in this challenging population.

Complications of Single-Incision Versus Dual-Incision Distal Biceps Repair A Systematic Review and Meta-Analysis of Comparative Studies.

PURPOSE: The purpose of this study was to systematically review and analyze the current evidence in the literature to determine the relative complication rates of the singleincision versus dual-incision approach to distal biceps tendon repair. METHODS: The literature search was performed based on the PRISMA guidelines. Cohort studies comparing the single-incision or dual-incision approach to biceps tendon repair alone were included. Clinical outcomes were compared, with all statistical analysis performed using Review Manager Version 5.3. A p-value < 0.05 was considered to be statistically significant. RESULTS: Twelve clinical studies with varying levels of evidence (LOE I: 1, LOE II: 1, LOE III: 10) with 2,429 patients were included. Overall, there was a significantly lower rate of total complications with the dual-incision approach (16.1% vs. 23.1%, p < 0.01) and a lower rate of neurological injuries (9.1% vs. 24.1%, p < 0.01). There was a lower rate of lateral antebrachial cutaneous nerve injuries with the dual-incision approach (5.2% vs. 19.5%, p < 0.01), and superficial radial nerve injuries (2.5% vs. 4.8%, p < 0.01), but there was no significant difference in the rate of posterior interosseous nerve injuries (2.2% vs. 1.2%, p = 0.20). There was a significantly lower rate of heterotopic bone formation with the single-incision approach (1.3% vs. 2.7%, p = 0.01). CONCLUSION: The dual-incision approach decreases the risk of total, overall postoperative complications and sensory nerve injuries following distal biceps repair. However, it has a higher risk of heterotopic bone formation.

Intraoperative Technology Use Improves Accuracy of Functional Safe Zone Targeting in Total Hip Arthroplasty.

BACKGROUND: Targets of acetabular inclination and anteversion have been suggested based on a patient's spinopelvic mobility. Current methods in total hip arthroplasty (THA) include manual instrumentation, computer-assisted navigation, and robotic-assisted surgery. This study aims to compare the accuracy of these 3 methods in targeting the functional safe zone. METHODS: This is a prospective multicenter study including a series of 251 consecutive primary posterior THA patients from April 2019 to January 2021. Preoperative lateral standing and sitting spinopelvic radiographs were obtained. Each patient was classified using the Hip-Spine Classification. A functional safe zone plan was determined. Surgeons used their preferred method (manual instrumentation, computer-assisted, or robotic-assisted). Postoperative anteversion and inclination was measured and compared to the preoperative plan. Mean differences between preoperative and postoperative values were calculated. Welch's t-test was used to assess significant between-group differences with P < .05 considered significant. RESULTS: Of the 249 patients, there were 63 manual instrumentation, 68 computer-assisted navigation, and 118 robotic-assisted surgery. Robotic-assisted surgery (rTHA) was significantly more accurate in targeting anteversion (1 ± 2) compared to manual instrumentation (mTHA; 7 ± 6, P < .001) and computer-assisted navigation (cTHA; 6 ± 6, P < .001). rTHA was also significantly more accurate in targeting inclination (1 ± 1) compared to mTHA (8 ± 7, P < .001) and cTHA (6 ± 7, P < .001). Although cTHA had greater accuracy in targeting both inclination and anteversion compared to mTHA, these differences were not statistically significant. CONCLUSION: Robotic-assisted surgery was more accurate than both computer-assisted navigation and manual instrumentation in targeting the functional safe zone in primary THA. Further research is needed to evaluate the effect of improved accuracy on dislocation rates.

Reverse Total Shoulder Arthroplasty Biomechanical Considerations and the Concept of Lateralization.

The biomechanical concepts underlying total shoulder arthroplasty including differences between the anatomic total and reverse total shoulder arthroplasty (RTSA) are reviewed. The concept of lateralization and its implications on outcomes after RTSA is explained through a historical perspective. Finally, how lateralization can be achieved via different components of an RTSA construct, as well as the potential disadvantages or trade-offs that must be considered when lateralizing in reverse shoulder arthroplasty, are discussed.

Acute Distal Triceps Tendon Rupture Repair: Case Presentation and Surgical Technique.

This case presentation and surgical technique demonstrates a complete distal triceps tendon rupture repair with single-row suture anchor fixation through a posterior midline approach to the elbow in a 17-year-old male rugby player. Key procedure points include complete triceps mobilization for adequate excursion to facilitate repair, identification of the ulnar nerve, isolation and sharp debridement of torn tissue to healthy tendon, thorough debridement of the olecranon reattachment site, suture construct, and order of fixation to optimize tendon-bone apposition.

Distance of the Posterior Interosseous Nerve From the Bicipital (Radial) Tuberosity at Varying Positions of Forearm Rotation: A Magnetic Resonance Imaging Study With Clinical Implications.

BACKGROUND: The proximity of the posterior interosseous nerve (PIN) to the bicipital tuberosity is clinically important in the increasingly popular anterior single-incision technique for distal biceps tendon repair. Maximal forearm supination is recommended during tendon reinsertion from the anterior approach to ensure the maximum protective distance of the PIN from the bicipital tuberosity. PURPOSE: To compare the location of the PIN on magnetic resonance imaging (MRI) relative to bicortical drill pin instrumentation for suspensory button fixation via the anterior single-incision approach in varying positions of forearm rotation. STUDY DESIGN: Descriptive laboratory study. METHODS: Axial, non-fat suppressed, T1-weighted MRI scans of the elbow were obtained in positions of maximal supination, neutral, and maximal pronation in 13 skeletally mature individuals. Distances were measured from the PIN to (1) the simulated path of an entering guidewire (GWE-PIN) and (2) the cortical starting point of the guidewire on the bicipital tuberosity (CSP-PIN) achievable from the single-incision approach. To radiographically define the location of the nerve relative to constant landmarks, measurements were also made from the PIN to (3) the prominent-most point on the bicipital tuberosity (BTP-PIN) and (4) a perpendicular plane trajectory from the bicipital tuberosity exiting the opposing radial cortex (PPT-PIN). All measurements were subsequently compared between positions of pronation, neutral, and supination. In supination only, BTP-PIN and PPT-PIN measurements were made and compared at 3 sequential axial levels to evaluate the longitudinal course of the nerve relative to the bicipital tuberosity. RESULTS: Of the 13 study participants, mean age was 38.77 years, and mean body mass index was 25.58. Five participants were female, and 5 left and 8 right elbow MRI scans were reviewed. The GWE-PIN was significantly greater in supination (mean ± SD, 16.01 ± 2.9 mm) compared with pronation (13.66 ± 2.5 mm) (P < .005). The mean CSP-PIN was significantly greater in supination (16.20 ± 2.8 mm) compared with pronation (14.18 ± 2.4 mm) (P < .013).The mean PPT-PIN was significantly greater in supination (9.00 ± 3.0 mm) compared with both pronation (1.96 ± 1.2 mm; P < .001) and neutral (4.73 ± 2.6 mm; P < .001). The mean BTP-PIN was 20.54 ± 3.0, 20.81 ± 2.7, and 20.35 ± 2.9 mm in pronation, neutral, and supination, respectively, which did not significantly differ between positions. In supination, the proximal, midportion, and distal measurements of BTP-PIN did not significantly differ. The proximal PPT-PIN distance (9.08 ± 2.9 mm) was significantly greater than midportion PPT-PIN (5.85 ± 2.4 mm; P < .001) and distal BTP-PIN (2.27 ± 1.8 mm; P < .001). CONCLUSION: This MRI study supports existing evidence that supination protects the PIN from the entering guidewire instrumentation during anterior, single-incision biceps tendon repair using cortical button fixation. The distances between the entering guidewire trajectory and PIN show that guidewire-inflicted injury to the nerve is unlikely during the anterior single-incision approach. CLINICAL RELEVANCE: When a safe technique is used, PIN injuries during anterior repair are likely the result of aberrant retractor placement, and we recommend against the use of retractors deep to the radial neck. Guidewire placement as close as possible to the anatomic footprint of the biceps tendon is safe from the anterior approach. MRI evaluation confirms that ulnar and proximal guidewire trajectory is the safest technique when using single-incision bicortical suspensory button fixation.

Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications?

BACKGROUND: The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS: A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS: In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION: Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.

The Effect of Platelet-Rich Plasma Leukocyte Concentration on Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of Randomized Controlled Trials.

BACKGROUND: It is unclear whether leukocyte-poor (LP) or leukocyte-rich (LR) varieties of platelet-rich plasma (PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) result in improved tendon healing rates. PURPOSE: To perform a network meta-analysis of the randomized controlled trials in the literature to ascertain whether there is evidence to support the use of LP- or LR-PRP as an adjunct to ARCR. METHODS: The literature search was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Randomized controlled trials comparing LP- or LR-PRP with a control alongside ARCR were included. Clinical outcomes, including retears and functional outcomes, were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score. RESULTS: There were 13 studies (868 patients) included, with 9 studies comparing LP-PRP with a control and 4 studies comparing LR-PRP with a control. LP-PRP was found to significantly reduce the rate of retear and/or incomplete tendon healing after fixation, even among medium-large tears; it also improved outcomes on the visual analog scale for pain, Constant score, and University of California Los Angeles score. LP-PRP had the highest P-score for all treatment groups. LR-PRP did not result in any significant improvements over the control group, except for visual analog scale score for pain. However, post hoc analysis revealed that LP-PRP did not lead to significant improvements over LR-PRP in any category. CONCLUSION: The current study demonstrates that LP-PRP reduces the rate of retear and/or incomplete tendon healing after ARCR and improves patient-reported outcomes as compared with a control. However, it is still unclear whether LP-PRP improves the tendon healing rate when compared with LR-PRP.

Preoperative Opioid Education has No Effect on Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Clinical Trial.

OBJECTIVES: The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients. METHODS: This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills. RESULTS: A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05). CONCLUSION: This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair. CLINICAL RELEVANCE: Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known. CLINICALTRIALSGOV IDENTIFIER: NCT04018768.

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in idiopathic adhesive capsulitis.

PURPOSE: To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with pre-existing validated outcome scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC). METHODS: Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcome scores were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were calculated. RESULTS: The final cohort included 100 patients with AC, of whom there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ± 1.84) compared with the fixed question burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed an excellent correlation with both the ASES (r = 0.80, 95% confidence interval [0.72, 0.86], P < .001) and CS (r = 0.76, 95% confidence interval [0.67, 0.83], P < .001). Neither ceiling nor floor effects were present. CONCLUSION: The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in AC. A lower question burden with the PROMIS UE carries potential for wider acceptability with the researchers and patients with shoulder pathology.

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty.

BACKGROUND: Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. METHODS: All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. RESULTS: Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. CONCLUSION: GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

A Preoperative Workup of a "Hip-Spine" Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem.

BACKGROUND: A large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA). METHODS: Achieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position. RESULTS: Based on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the "Hip-Spine Classification in THA." A series of illustrative case examples is provided. CONCLUSION: A simple three-step assessment with minimal measurements will effectively identify the complex "hip-spine" THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

PURPOSE: The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS: The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS: A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION: Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE: III.

Salvage of failed internal fixation of intertrochanteric hip fractures: clinical and functional outcomes of total hip arthroplasty versus hemiarthroplasty.

BACKGROUND: Failed internal fixation of intertrochanteric (IT) hip fractures presents a significant challenge in the elderly, osteoporotic population. Conversion total hip arthroplasty (cTHA) and hemiarthroplasty (cHA) are both accepted salvage operations for failed IT fracture fixation, though limited clinical data exist regarding the optimal treatment between these procedures. METHODS: A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were English-language studies that compared clinical or functional outcomes after failed fixation of IT fractures with total hip arthroplasty and hemiarthroplasty in adult subjects (>18 years of age). Data regarding research design, surgical technique, and clinical or functional outcomes were obtained and analyzed from eligible studies using a Mantel-Haenszel random-effects analysis model. RESULTS: Six studies with 188 patients (100, total hip arthroplasty; 88, hemiarthroplasty) met inclusion and exclusion criteria. There was no significant difference between cTHA and cHA for postoperative dislocation, reoperation, infection, intraoperative fractures, postoperative fractures, or stem subsidence. The mean change in Harris Hip Scores was significantly higher (P < .001) in the cTHA group (47.5 ± 4.9) than that in the cHA (38.9 ± 7.2) group at minimum 14-month follow-up. CONCLUSIONS: Despite potential advantages of cTHA or cHA for failed IT fractures, there were no differences in complications between either of the salvage procedures. Our analysis found a slight advantage in functional outcomes (Harris Hip Score) for cTHA at a minimum 14-month follow-up. Our study suggests that cTHA and cHA are both effective salvage procedures. Additional prospective studies are warranted to further delineate outcomes after salvage arthroplasty performed for failed IT fracture fixation.

Biomechanical Performance of Medial Row Suture Placement Relative to the Musculotendinous Junction in Transosseous Equivalent Suture Bridge Double-Row Rotator Cuff Repair.

PURPOSE: To compare the biomechanical performance of medial row suture placement relative to the musculotendinous junction (MTJ) in a cadaveric transosseous equivalent suture bridge (TOE-SB) double-row (DR) rotator cuff repair (RCR) model. METHODS: A TOE-SB DR technique was used to reattach experimentally created supraspinatus tendon tears in 9 pairs of human cadaveric shoulders. The medial row sutures were passed either near the MTJ (MTJ group) or 10 mm lateral to the MTJ (rotator cuff tendon [RCT] group). After the supraspinatus repair, the specimens underwent cyclic loading and load to failure tests. The localized displacement of the markers affixed to the tendon surface was measured with an optical tracking system. RESULTS: The MTJ group showed a significantly higher (P = .03) medial row failure (5/9; 3 during cyclic testing and 2 during load to failure testing) compared with the RCT group (0/9). The mean number of cycles completed during cyclic testing was lower in the MTJ group (77) compared with the RCT group (100; P = .07) because 3 specimens failed in the MTJ group during cyclic loading. There were no significant differences between the 2 study groups with respect to biomechanical properties during the load to failure testing. CONCLUSIONS: In a cadaveric TOE-SB DR RCR model, medial row sutures through the MTJ results in a significantly higher rate of medial row failure. CLINICAL RELEVANCE: In rotator cuff tears with tendon tissue loss, passage of medial row sutures through the MTJ should be avoided in a TOE-SB RCR technique because of the risk of medial row failure.