An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013.

BACKGROUND: The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS: A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS: A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS: The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction.

PURPOSE: Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS: New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS: The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION: A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE: Level III.

Improvement in sleep quality after total shoulder arthroplasty.

Objective: Poor sleep quality due to nocturnal pain is increasingly reported as a major symptom in advanced glenohumeral arthritis. The current study aimed to evaluate preoperative and postoperative sleep quality, shoulder pain, and function in patients who underwent total shoulder arthroplasty (TSA). Preoperative factors contributing to delayed improvements in sleep quality were examined.Methods: Patients scheduled for anatomic or reverse TSA due to glenohumeral arthritis were included. Patients completed the Pittsburgh Sleep Quality Index (PSQI) and American Shoulder and Elbow Surgeons (ASES) survey preoperatively, and at 6 weeks, 3 months, 6 months, and 1 year following surgery. A higher PSQI score (maximum 21) indicated greater sleep disturbance.Results: Seventy-four patients (34 males, 40 females), with a mean age of 65.8 years were prospectively enrolled. Eighty-four percent of patients reported preoperative PSQI scores indicative of sleep disturbance (6 or greater), with a mean of 10.1 ± 4.3. The PSQI score significantly improved to 7.7 at 6 weeks (P = .003), and to 6.1 at 3 months (P = .08). At 12 months, the PSQI was within normal limits (less than or equal to 5) with a mean score of 4.3. A normal PSQI score was achieved by 40.8%, at 6 weeks, 50% at 3 months, 53.7% at 6 months, and 73.9% at 1 year. The ASES score significantly improved from 32.6 ± 17.2 at baseline to 58.4 at 6 weeks (p < .001), 76.1 at 3 months (p < .001), and 85.3 at 12 months. Linear regression demonstrated that the ASES and PSQI scores were negatively associated with each other at each time point. Body mass index and female gender were associated with a delayed return to baseline sleep quality.Conclusion: Shoulder-related sleep disturbance significantly improved at 6 weeks following TSA, and normalized for most patients by 1 year post-operatively. Enhanced sleep quality after TSA was directly related to improved functional outcomes.

High Ankle Sprains in Professional Ice Hockey Players: Prognosis and Correlation Between Magnetic Resonance Imaging Patterns of Injury and Return to Play.

BACKGROUND: Hockey players sustain a greater incidence of ankle syndesmosis injuries than other athletes. These injuries have a higher morbidity and more unpredictable recovery than lateral ankle sprains. Magnetic resonance imaging (MRI) has been used to establish the diagnosis but has not been evaluated for its ability to predict return to play. HYPOTHESIS: We hypothesized that patterns of injury defined on MRI could be used to predict return to play in a cohort of professional hockey players with syndesmosis sprains. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A prospectively collected National Hockey League (NHL) database was analyzed from the 2006-2007 to 2011-2012 seasons to assess return to play after an injury. A separate retrospective review of ankle MRI scans from professional hockey players with a documented high ankle sprain sustained between 2007 and 2012 was performed. Injuries were classified on MRI as complete or partial tears of the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL), and deltoid ligament. Fractures, bone contusions, and osteochondral lesions were also recorded. RESULTS: A total of 105 NHL athletes sustained high ankle sprains over the 5 seasons studied. Of these athletes, 85 were unable to play and missed a median of 8 games (range, 0-65 games). A retrospective MRI evaluation of 21 scans identified complete AITFL tears in 13 (62%) and high-grade partial tears in 5 (24%) cases. In contrast, the PITFL was partially torn in 9 (43%) and normal in 12 (57%) cases. Bone contusions were seen in 71% of cases and lacked a consistent pattern. The most commonly associated ligamentous injury was of the ATFL, which was injured in 52% of cases (11/21; 3 complete and 8 partial). There was no difference in the mean number of days lost when players were stratified by patterns of injury (incomplete/complete AITFL tear ± additional ligamentous injury, bone contusion, syndesmosis width). CONCLUSION: A high ankle sprain resulted in significant variations in time of recovery among professional hockey players. A torn AITFL and bone bruising were the most common patterns of injury. Although MRI can be used to confirm the diagnosis of a syndesmosis injury, it did not predict return to play in this population.

Neuropathic Arthropathy of the Glenohumeral Joint A Review of the Literature.

Neuropathic arthropathy, also known as Charcot arthropathy, is a degenerative disorder most commonly characterized by rapid destruction of the joint with extensive involvement of the bone and soft tissue. The underlying pathophysiology is thought to be due to loss of nociception (pain sensation), most frequently caused by diabetes mellitus, syphilitic myelopathy, or syringomyelia. A neuropathic shoulder is rare, with historic case series forming the bulk of the literature. The purpose of this review is to better understand the pathogenesis, clinical presentation, and management of neuropathic arthropathy of the glenohumeral joint. It should be stressed that the identification and management of the underlying etiology is paramount if the disease process is to be positively impacted. Although the mainstay of orthopedic management is non-surgical, little evidence exists to support the use of any specific therapeutic intervention. Recent literature suggests surgical reconstruction may be considered in very select patients.

Cryopreserved bone allograft for the treatment of shoulder instability with glenoid defect.

The purpose of this study was to examine outcomes after cryopreserved tri-cortical iliac crest allograft reconstruction for glenoid bone loss in patients with shoulder instability. 10 patients completed the required assessments at a mean follow up of 4.5 years. At final follow up, mean ASES was 92 ±â€¯12, mean WOSI was 315 ±â€¯319, with good range of motion. None of the final radiographs demonstrated graft resorption or failure of hardware. The data demonstrated that patients who were treated with glenoid bone grafting with cryopreserved tri-cortical iliac crest allograft can expect good range of motion and functional capacity.

Independent Risk Factors for Revision Surgery or Conversion to Total Hip Arthroplasty After Hip Arthroscopy: A Review of a Large Statewide Database From 2011 to 2012.

PURPOSE: To use a large heterogeneous population to identify independent risk factors for revision surgery or conversion to total hip arthroplasty (THA) after hip arthroscopy. METHODS: The New York Statewide Planning and Research Cooperative System database was queried from 2011 through 2012 to identify patients undergoing hip arthroscopy. All patients aged 18 years or older who underwent hip arthroscopy according to Current Procedural Terminology coding were included. We chose to divide surgical volume into tertiles for the purposes of statistical analysis. Longitudinal analysis for a minimum of 2 years was performed to determine risk factors for revision surgery or conversion to THA. RESULTS: We identified 3,957 patients. The mean age was 35.8 years (standard deviation, 13.1 years). After a minimum follow-up period of 2 years, the overall failure rate was 9.6%: 3.7% of patients underwent revision hip arthroscopy at an average of 15.8 months, whereas 5.9% underwent conversion to THA at 14.7 months. Index surgery performed by surgeons in the third tertile of surgical volume (<40 cases per annum) was an independent risk factor for revision (odds ratio [OR], 1.71; P = .001), as well as conversion to THA (OR, 1.90; P < .001). Female patients (OR, 1.8; P < .001), older patients (OR, 3.4; P < .001), and patients with a history of obesity (OR, 5.6; P < .001) underwent conversion to THA at significantly higher rates than other patients. Young patients (OR, 4.4; P < .001) and female patients (OR, 1.6; P < .001) were more likely to undergo revision hip arthroscopy. CONCLUSIONS: Our analysis of 3,957 patients found that female sex, age under 40 years, absence of a labral repair, and index procedure performed by a low-volume surgeon were independent risk factors for revision hip arthroscopy. Age over 60 years, index procedure performed by a low-volume surgeon, female sex, obesity, and the presence of pre-existing arthritis were risk factors for THA conversion. LEVEL OF EVIDENCE: Level III, case-control study.

Impact of Diabetes on Perioperative Complications in Patients Undergoing Elective Total Shoulder Arthroplasty.

INTRODUCTION: Diabetes has been associated with negative outcomes following orthopaedic surgery. While previous studies have reported on diabetes-associated complications in shoulder arthroplasty, those cohorts were heterogeneous in terms of patient population, nature of elective surgery, and arthroplasty type. Given that the number of elective total shoulder arthroplasties (TSAs) performed has grown substantially in volume and is predicted to rise even further, it is important to recognize the role that diabetes may play in developing in-hospital complications within a more homogenous sample of patients undergoing elective TSA. METHODS: The Nationwide Inpatient Sample (NIS) was searched for the year 2012 to identify all patients undergoing elective TSA. Patients with diabetes were identified, and differences regarding demographics and in-hospital outcomes were compared to non-diabetics using multivariate logistic regression. RESULTS: A total of 44,050 patients underwent elective total shoulder arthroplasty (TSA) in 2012. Diabetic patients tended to be older, of minority racial status, and had a greater medical comorbidity burden. When controlling for preoperative factors and comorbidities, diabetes was an independent risk factor for non-home bound discharge (OR 1.285; 95% CI 1.093-1.509, p = 0.002), length of stay in 75th percentile (OR 1.390; 95% CI 1.233-1.567, p < 0.001), total charges in the 75th percentile (OR 1.136; 95% CI 1.006-1.283, p = 0.040), and postoperative acute renal failure (OR 1.460; 1.002-2.128, p = 0.048). CONCLUSION: Diabetes was associated with marginal increases in non-home bound discharge, length of stay, and total charges, following elective TSA. Subgroup analysis revealed that diabetic patients undergoing reverse total shoulder arthroplasty (rTSA) have higher comorbidity burden and worse outcomes than diabetic patients undergoing anatomic total shoulder arthroplasty (aTSA).

Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis.

BACKGROUND: Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA). METHODS: A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission. RESULTS: 4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA. CONCLUSION: After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.

Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials.

Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965.

Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders.

BACKGROUND: Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. METHODS: We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. RESULTS: Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching. CONCLUSIONS: This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

Two-stage revision for infected shoulder arthroplasty.

BACKGROUND: Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because 2-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs. METHODS: We identified 19 patients (14 men) from our institution who were treated with a 2-stage revision after presenting with a PSI. Mean patient age was 63 ± 9 years, and average body mass index was 30.8 ± 5.8. The average time from the index arthroplasty to treatment was 40 months, 8 of 13 positive cultures were Propionibacterium acnes, and 9 of 19 patients had multiple shoulder operations before presenting with infection. Minimum follow-up for all patients was 2 years. RESULTS: After a mean follow-up of 63 months (range, 25-184 months), 15 of 19 patients in our study were successfully treated for PSI. Average postoperative American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment score was 69 (range, 32-98) and average postoperative forward elevation was significantly increased from 58° to 119° (P < .001). The incidence of recurrent infection was 26%. The rate of noninfection complications was 16%, for a total complication rate of 42%. CONCLUSION: In patients with PSIs, especially those with intractable, chronic infections, a 2-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population.

Arthroscopic Repair of Type II SLAP Tears Using Suture Anchor Technique.

Arthroscopic SLAP tear repair has become an increasingly used treatment for patients presenting with symptomatic SLAP tears after failed nonoperative management. Debridement, SLAP repair, and open or arthroscopic biceps tenodesis or tenotomy have been used for the treatment of SLAP tears. Various techniques for repair have been described, and furthermore, there is a high incidence of concomitant pathology of the shoulder. Repair remains an excellent option in isolated SLAP tears amenable to repair, with excellent outcomes in well-indicated patients. We present a method for repairing a SLAP tear using standard suture anchor fixation, anterior and posterior portals, and an accessory portal of Wilmington. Adequate labral repair can be achieved with this technique in patients with no concomitant biceps pathology. This report highlights this technique for SLAP repair in patients with isolated symptomatic SLAP tears that have failed conservative management.

Definitive Treatment of Infected Shoulder Arthroplasty With a Cement Spacer.

Infection in the setting of shoulder arthroplasty can result in significant pain, loss of function, and the need for additional surgery. As the use of shoulder arthroplasty increases, the medical and economic burdens of periprosthetic joint infection increase as well. The ideal management of infected shoulder prostheses has not been established. This report describes 9 patients from a single institution who had an infected shoulder arthroplasty that was definitively managed with a cement spacer. All patients had a minimum of 2 years of follow-up. Of the 9 patients in this study, 6 were men. Mean age was 73±9 years. Of the study patients, 1 had diabetes, 2 presented with Parkinson's disease, and 5 had a history of tobacco use. Average body mass index was 27.9±7 kg/m(2). After mean follow-up of 4 years, none of the patients had clinical or radiographic evidence of infection. Functional outcomes, as measured by American Shoulder and Elbow Surgeons scores, were good or fair in 89% of patients, and the average American Shoulder and Elbow Surgeons score was 57. A review of recent literature suggested that the current findings were similar to those in studies reporting 1- or 2-stage revision procedures. Although cement spacers are typically used as part of a 2-stage revision procedure, the current findings suggest that cement spacers can be used effectively to eradicate infection and allow for acceptable functional recovery and range of motion in patients who have severe medical comorbidities and cannot tolerate additional surgery. [Orthopedics. 2016; 39(5):e924-e930.].

Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review.

BACKGROUND: Medial ulnar collateral ligament (UCL) injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction (UCLR) procedures is rapidly increasing. We sought to quantify the incidence of age-related trends for UCLR from 2003 to 2014 and subsequently to project future trends through 2025. We hypothesized that as the total number of UCLRs performed increased, a disproportionate incidence among younger patients would be observed. METHODS: New York State's Statewide Planning and Research Cooperative System database was queried from 2003 to 2014 to identify individuals between 10 and 40 years old undergoing UCLR. Poisson regression was used to develop future projections for UCLR and New York State population through 2025, and incidence estimates per 100,000 people were calculated. RESULTS: In New York State between 2003 and 2014, there were 890 patients who underwent UCLR, with average annual incidence per 100,000 people equaling 6.3 ± 2.8 for ages 15 to 19 years, significantly greater than for all other age groups (P < .001). Projections from 2015 through 2025 suggest that incidence in 15- to 19-year-olds and 20- to 24-year-olds will continue to rapidly increase while rates for other age groups will remain relatively stable. CONCLUSIONS: The number of UCLRs performed between 2003 and 2014 increased by 343%, and a disproportionate trend in average annual incidence for patients between 15 and 19 years old was observed. As our review of the literature questioned outcomes in adolescent athletes after UCLR, continued attempts at preventing these injuries in the young throwing athlete remain paramount.

Impact of Race and Gender on Utilization Rate of Total Shoulder Arthroplasty.

Marked underutilization rates of total joint arthroplasty in minorities compared with nonminorities exist, with a paucity of literature surrounding inequities related to total shoulder arthroplasty (TSA). Using the Statewide Planning and Research Cooperative System database, patients who underwent elective TSA in New York State (NYS) were identified and characterized by age, race, gender, medical comorbidities, and payor status. Patients were stratified into 4 separate 5-year periods from 1990 to 2009. Comorbidity severity was defined using the Elixhauser criteria. A total of 10,538 elective TSAs were identified, with half of the procedures occurring in the most recent time quartile. Whites accounted for 70% of the procedures, whereas blacks accounted for 5%. During the 20-year period, the age-adjusted incidence of TSA in white men and women increased by 417% and 421%, respectively, whereas the incidence for black men and women increased by 378% and 329%, respectively. Black men had the lowest utilization rate among all subgroups, and overall disparity between races continued to widen over time. Blacks had significantly more comorbid conditions (P<.001) than whites when undergoing TSA. Blacks were more likely to have Medicaid insurance and less participation in Medicare (P<.001). Racial and gender disparities clearly exist in TSA utilization rates in NYS and may be worsening. Although reasons for these disparities are likely multifactorial, a deeper understanding of the factors involved in patient selection and access to care is necessary to appropriately address these disparities and effect change at a system-wide patient and provider level. [Orthopedics. 2016; 39(3):e538-e544.].

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair.

PURPOSE: To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR). METHODS: We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored. RESULTS: Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P = .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P < .001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001). CONCLUSIONS: We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Subsequent Shoulder Surgery After Isolated Arthroscopic SLAP Repair.

PURPOSE: To quantify the incidence of and identify the risk factors for subsequent shoulder procedures after isolated SLAP repair. METHODS: New York's Statewide Planning and Research Cooperative System database was searched between 2003 and 2014 to identify individuals with the sole diagnosis of a SLAP lesion who underwent isolated arthroscopic SLAP repair. Patients were longitudinally followed up for a minimum of 3 years to analyze for subsequent ipsilateral shoulder procedures. RESULTS: Between 2003 and 2014, 2,524 patients met our inclusion criteria. After 3 to 11 years of follow-up, 10.1% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair. The mean time to repeat shoulder surgery was 2.3 ± 2.1 years. Subsequent procedures included subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.36-6.21; P = .005), whereas age older than 30 years was an independent risk factor for subsequent acromioplasty (OR, 2.3; 95% CI, 1.4-3.7; P < .001) and distal clavicle resection (OR, 2.5; 95% CI, 1.1-5.5; P = .030). The need for a subsequent procedure was significantly associated with Workers' Compensation cases (OR, 2.4; 95% CI, 1.7-3.2; P < .001). CONCLUSIONS: We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years. LEVEL OF EVIDENCE: Level III, case-control study.

Impact of glenosphere size on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 297 shoulders.

BACKGROUND: Although increasing glenosphere diameter has been found to increase passive range of motion (ROM) in simulated models of reverse total shoulder arthroplasty (rTSA), the clinical implications of glenosphere size are unclear. The purpose of our study was to determine the impact that glenosphere size had on short-term and midterm clinical outcomes, specifically American Shoulder and Elbow Surgeons (ASES) scores and ROM. METHODS: Prospectively collected data comparing patients receiving an rTSA with either a 38- or 42-mm glenosphere after a minimum 2-year follow-up were obtained. Clinical outcome measures included active ROM and ASES scores. RESULTS: We included 297 primary rTSAs in 290 patients: a 38-mm-diameter glenosphere was used in 160 shoulders and a 42-mm-diameter glenosphere in 137 shoulders. Of the patients, 191 were women and 99 were men. The mean age at the time of surgery was 72 years (range, 50-88 years). At last follow-up, improvements in active forward elevation (aFE) and active external rotation (aER) were significantly greater in shoulders with a 42-mm glenosphere (+59° vs +44° for aFE and +24° vs +18° for aER). Female shoulders treated with a 42-mm glenosphere had significantly greater improvements in aFE, aER, and functional scores. Male shoulders treated with a 38-mm glenosphere had significantly greater improvements in pain levels and ASES scores but less improvement in aFE. Complications and rates of scapular notching were similar between glenosphere sizes. CONCLUSIONS: Patients treated with 42-mm glenospheres had greater improvements in aFE and aER when compared with 38-mm glenospheres. Our results suggest a potential association among gender, glenosphere size, and improvement in clinical outcome scores. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Design; Treatment Study.