Wound Healing: Cellular Review With Specific Attention to Postamputation Care.

Wound healing is crucial for survival, prevention of infection, and restoration of tissue function. The immune system drives this process with 3 main phases: inflammation, proliferation, and remodeling. Keloids and hypertrophic scars reveal disruptions in these phases, underscoring the balance needed for healing. Limb amputation, a life-changing event, demands careful consideration for healing and function. Factors such as amputation level, surgical technique, and prosthetic fitting shape outcomes, while complications such as heterotopic ossification challenge recovery. Treatment advances including statins and stem cell therapy hold promise, with dermatologists poised to contribute substantially to postamputation care.

Risk factors for postoperative blood transfusion after shoulder arthroplasty.

Purpose: To identify the effect of surgical indication, patient factors, and perioperative characteristics on transfusion after shoulder arthroplasty (SA). Methods: Shoulder arthroplasties for osteoarthritis (OA) (N = 47), rotator cuff arthropathy (RCA) (N = 50), fracture (N = 76), revision (N = 66), and periprosthetic joint infection (PJI) (N = 35) performed at a single institution during a 6-year period were included. All other indications were excluded. Patient-based and surgical risk factors, including surgical indication, for postoperative allogeneic red blood cell transfusion were assessed with multivariate logistic regression analysis. Results: A total of 274 SAs were included; transfusions were performed in 2% (2/97) of primary SAs for OA or RCA. Increased transfusion rates occurred in PJI (23%, p = 0.0006) and fracture (18%, p = 0.0018) cases. The mean preoperative hemoglobin (Hgb) was 12.2 ± 2.2 with PJI, 12.0 ± 2.1 with fracture, and 13.3 ± 1.6 g/dL for all other SAs. Independent risk factors for transfusion included lower preoperative hemoglobin (p < 0.001), PJI indication (p = 0.008), and fracture indication (p = 0.02), with no difference for fracture greater or less than 4 weeks old (p = 0.53). Conclusion: Risk factors for allogeneic red blood cell transfusion after SA were low preoperative hemoglobin and procedures for PJI or fracture.Level of Evidence: Level III, retrospective case-control study.

Pectoralis muscle injuries in Major and Minor League Baseball.

BACKGROUND AND HYPOTHESIS: Although shoulder and elbow injuries in professional baseball players have been thoroughly studied, little is known about the frequency and impact of pectoralis muscle injuries in this population. The purpose of this study was to use the official league injury surveillance system to describe pectoralis muscle injuries in professional baseball players in Major League Baseball (MLB) and Minor League Baseball (MiLB). Specifically, (1) player demographic characteristics, (2) return to play (RTP), (3) injury mechanism, (4) throwing- and batting-side dominance, and (5) injury rate per athlete exposure (AE) were characterized to guide future injury prevention strategies. METHODS: The MLB Health and Injury Tracking System database was used to compile all pectoralis muscle injuries in MLB and MiLB athletes in the 2011-2017 seasons. Injury-related data including diagnosis (tear or rupture vs. strain), player demographic characteristics, injury timing, need for surgical intervention, RTP, and mechanism of injury were recorded. Subanalyses of throwing- and batting-side dominance, as well as MLB vs. MiLB injury frequency, were performed. RESULTS: A total of 138 pectoralis muscle injuries (32 MLB and 106 MiLB injuries) were reported in the study period (5 tears or ruptures and 133 strains), with 5 of these being recurrent injuries. Operative intervention was performed in 4 athletes (2.9%). Of the 138 injuries, 116 (84.1%) resulted in missed days of play, with a mean time to RTP of 19.5 days. Starting pitchers sustained the greatest proportion of pectoralis injuries (48.1%), with pitching being the most common activity at the time of injury (45.9%). A majority of injuries (86.5%) were sustained during non-contact play. Overall, 87.5% of injuries occurred on the player's dominant throwing side and 81.3% occurred on the player's dominant batting side. There was no significant difference in the rate of pectoralis injuries in the MLB regular season (0.584 per 10,000 AEs) vs. the MiLB regular season (0.425 per 10,000 AEs) (P = .1018). CONCLUSION: Pectoralis muscle injuries are most frequently non-contact injuries, most commonly sustained by pitchers. An understanding of these injuries can guide athletic trainers and management in expectation management and decision making, in addition to directing future efforts at injury prevention.

Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty.

Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.

Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes.

BACKGROUND: Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited. METHODS: The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations. RESULTS: A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge. CONCLUSION: Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency.

PURPOSE: We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes. METHODS: Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected. RESULTS: The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present. CONCLUSION: Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes. LEVEL OF EVIDENCE: IV, retrospective cohort.

Epidemiology of acromioclavicular joint injuries in professional baseball: analysis from the Major League Baseball Health and Injury Tracking System.

BACKGROUND: Shoulder injuries account for a large portion of all recorded injuries in professional baseball. Much is known about other shoulder pathologies in the overhead athlete, but the incidence and impact of acromioclavicular (AC) joint injuries in this population are unknown. We examined the epidemiology of AC joint injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players and determined the impact on time missed. METHODS: The MLB Health and Injury Tracking System was used to compile records of all MLB and MiLB players from 2011 to 2017 with documented AC joint injuries. These injuries were classified as acute (sprain or separation) or chronic (AC joint arthritis or distal clavicular osteolysis), and associated data extracted included laterality, date of injury, player position, activity, mechanism of injury, length of return to play, and need for surgical intervention. RESULTS: A total of 312 AC joint injuries (183 in MiLB players and 129 in MLB players; range, 39-60 per year) were recorded: 201 acute (64.4%) and 111 chronic (35.6%). A total of 81% of acute and 59% of chronic injuries resulted in time missed, with a mean length of return to play of 21 days for both. Of the injuries in outfielders, 79.6% were acute (P < .0001), as were 66.3% of injuries in infielders (P = .004). Pitchers and catchers had more equal proportions of acute and chronic AC injuries (P > .05 for all). Acute AC injuries occurred most often while fielding (n = 100, 84.7%), running (n = 25, 80.6%), and hitting (n = 19, 61.3%), whereas chronic injuries tended to be more common while pitching (n = 26, 68.4%). Of contact injuries, 82.5% were acute (P < .0001), whereas 59.0% of noncontact injuries were chronic (P = .047). MLB players showed consistently higher regular-season rates of both acute and chronic AC injuries than MiLB players (P < .0001 for each). CONCLUSION: Acute AC joint injuries are contact injuries occurring most commonly among infielders and outfielders while fielding that result in 3 weeks missed before return to play, whereas chronic AC joint injuries occur more commonly in pitchers and catchers from noncontact repetitive overhead activity. Knowledge of these data can better guide expectation management in this elite population to better elucidate the prevalence of 2 common injury patterns in the AC joint.

Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review.

BACKGROUND: Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years. PURPOSE: To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear. STUDY DESIGN: Systematic review. METHODS: A systematic review was performed for any articles published before July 2019. The search phrase "labral tear" was used to capture maximum results, followed by keyword inclusion of "SLAP tear" and "biceps tenodesis." Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined. RESULTS: After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals. CONCLUSION: BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

What Are the Effects of Remplissage on 6-Month Strength and Range of Motion After Arthroscopic Bankart Repair? A Multicenter Cohort Study.

BACKGROUND: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM). HYPOTHESIS: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect. RESULTS: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction (P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane (P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors (P = .003), increased patient age (P = .02), and preoperative side-to-side deficits in ER (P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness (P = .04), with no association with remplissage (P = .26). CONCLUSION: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.

Targeted Muscle Reinnervation at the Time of Major Limb Amputation in Traumatic Amputees: Early Experience of an Effective Treatment Strategy to Improve Pain.

BACKGROUND: Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. METHODS: Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. RESULTS: At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. CONCLUSIONS: The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review.

PURPOSE OF REVIEW: Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years. RECENT FINDINGS: The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.

Bullous eruption caused by an exotic hedgehog purchased as a household pet.

An unusual case of a 37-year-old woman with bullous tinea manuum caused by an infection with Trichophyton mentagrophytes is described. The patient presented with a pruritic erythematous vesicular rash on the right palm and interdigital web spaces between the first and second digits. The preliminary diagnosis was acute contact dermatitis, which was treated with oral and topical corticosteroids. The rash failed to respond to treatment, resulting in tinea incognito. At 2-week follow-up, a potassium hydroxide (KOH) preparation performed in clinic was positive for T mentagrophytes. The suspected source of infection was a domestic 4-toed, white-bellied African pygmy hedgehog (Atelerix albiventris). There was remarkable improvement of the lesion after 2 weeks with appropriate topical and systemic antifungal agents. This case illustrates that popular exotic pets such as the hedgehog can increase the risk for zoophilic dermatophytic infection, which can present as bullous lesions with little or no scale and can be confused with acute contact dermatitis. It is important for the clinician to recognize this presentation and provide close follow-up for lesions not responding to treatment.

Superior Labral Anterior Posterior Repair and Biceps Tenodesis Surgery: Trends of the American Board of Orthopaedic Surgery Database.

BACKGROUND: Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic. PURPOSE: To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827). RESULTS: A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years (P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair (P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) (P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) (P < .001). CONCLUSION: The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.

High prevalence of outpatient falls following elective shoulder arthroplasty.

BACKGROUND: This study characterized the prevalence and risk factors of inpatient and outpatient postoperative falls in patients undergoing elective shoulder arthroplasty. METHODS: A retrospective chart review of 198 patients undergoing anatomic or reverse total shoulder arthroplasty or hemiarthroplasties at one institution between 2015 and 2017 was reviewed to determine the prevalence of inpatient and outpatient falls up to 90 days after discharge. Univariate and multivariate analyses were conducted to assess potential risk factors for postoperative falls including demographics, indication for surgery, surgical procedure, medical history, length of hospital stay, perioperative hemoglobin, need for transfusion, and discharge disposition. RESULTS: There were 23 falls in 22 patients within a 90-day postoperative period. The inpatient fall rate was 1.0% (2 of 198). The outpatient fall rate was 10.6% (21 of 198). Outpatient falls resulted in emergency department evaluation in 23.8% of cases (5 of 21), readmission in 19.0% (4 of 21), injury to an anatomic site other than the shoulder in 19.0% (4 of 21), and injury at the surgical site (eg, periprosthetic humeral fracture) in 4.8% (1 of 21). No significant risk factors were identified for inpatient falls. Independent risk factors for an outpatient fall were female sex (adjusted odds ratio [aOR] = 4.79; 95% confidence interval [CI]: 1.32, 17.4; P = .007), increased length of hospital stay (aOR = 1.23; 95% CI: 1.04, 1.45; P = .02), and history of a movement disorder (aOR = 7.20; 95% CI: 1.22, 42.6; P = .03). CONCLUSION: A high outpatient fall rate of 10.6% within 90 days after discharge raises the concern that falls after shoulder arthroplasty are significantly higher than previously reported.

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study.

BACKGROUND: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. PURPOSE: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports. RESULTS: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02). CONCLUSION: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

Efficacy of Applicator Devices for Self-Application of Topicals to the Back.

BACKGROUND: Self-application of topicals on the back can be challenging. OBJECTIVE: The aim was to assess topical back coverage using commercially available back applicators. MATERIALS AND METHODS: Ten subjects applied sunscreen to their back using their hands and then with 3 back applicators (large foam tip, small foam tip, roller tip). The amount of lotion used and the time it took to perform the application were recorded. The resulting distribution of sunscreen was assessed with a Wood's lamp; the area covered fluoresced less than the uncovered skin. Images were captured and then analyzed using an automated thresholding technique. RESULTS: Subjects applied more lotion when using the large foam tip (7.58 g, 95% CI 6.47-8.70 g; P < .004) and small foam tip (7.46 g, 95% CI 6.35-8.57 g; P < .006) applicators compared to hands alone (6.22 g, 95% CI 5.10-7.33 g). Application time was longer with the small foam tip applicator (113.4 s, 95% CI 96.7-130.1 s) relative to hand application (78.7 s, 95% CI 62-95.4 s) (P < .03). Coverage of the back was higher for the large foam tip (84.8%, 95% CI 78.4%-91.3%; P < .03), small foam tip (88.0%, 95% CI 81.6%-91.5%; P < .006), and roller tip (84.3%, 95% CI 77.9%-90.8%; P < .04) applicators compared to hand application (71.5%, 95% CI 65%-78%). The middle back tended to have less coverage when applying with the hands. CONCLUSIONS: Topical coverage of the back is improved with the use of applicator devices during self-application.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship-trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, "How soon after your carpal tunnel surgery did you notice an improvement in your sleep?" Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.