Anatomic total shoulder arthroplasty with inlay glenoid component: A systematic review.

Background: A total shoulder arthroplasty (TSA) system utilizing an inlay glenoid component has been proposed as a means of reducing glenoid component loosening while still providing patients with desirable functional and clinical outcomes. The purpose of this study was to systematically review current outcomes literature on TSA using an inlay glenoid component. Methods: A literature search was conducted using PubMed/MEDLINE, Cochrane Database of Systematic Reviews, and Web of Science databases. Studies comparing pre- and postoperative functional and clinical outcomes were included. Results: Five studies with 148 shoulders (133 patients) were included. Patient-reported outcomes improved, including the American Shoulder and Elbow Surgeons score (mean change 34.1 to 80.6), Penn Shoulder Score (mean change 43.3 to 85.5), Single Assessment Numeric Evaluation score (mean change 34.1 to 80.6), and visual analog scale-pain (mean change 6.9 to 1.6). Range of motion improved for forward elevation (mean change 109.6 to 156.2) and external rotation (mean change 21.5 to 50.8). Glenoid component loosening occurred in one shoulder (0.68%). Two revision surgeries (1.35%) were performed. Discussion: The use of an inlay glenoid component is associated with improvements in postoperative pain, function, and satisfaction while minimizing rates of glenoid component loosening and the need for revision surgery over short-term follow-up. Level of evidence: systematic review, level IV.

Outcomes of the Latarjet procedure in female patients: A case series and matched-pair analysis.

Background: The objective of this study was to retrospectively report on the outcomes of female patients undergoing the Latarjet procedure. Methods: Female patients undergoing the Latarjet procedure with minimum 1 year follow-up were identified and contacted to obtain Numeric Pain Rating Scale (NPRS), Subjective Shoulder Value (SSV), and return to sport (RTS) data. Eligible females were then matched 1:1 with a male counterpart based on laterality and age (± 3 years), and outcomes compared. Results: A total of 20 female patients with a mean follow-up of 73.8 months reported postoperative NPRS and SSV scores of 2.2 ± 2.3 and 69.3 ± 22.0, respectively. Of the nine athletes, 3 (33%) reported a successful RTS at a mean of 9 months. Four patients (20.0%) required reoperation at a mean of 27.1 months. The matched analysis demonstrated similar NPRS scores between male and female patients and a trend towards lower SSV scores and rates of RTS. Conclusion: At mid-term follow-up female patients reported pain levels similar to female-specific literature reports, but overall low subjective shoulder function and RTS. Compared to propensity-matched males, females reported similar levels of pain, lower shoulder function, and lower rates of RTS, however, differences did not reach statistical significance. Level of Evidence: IV, retrospective case series.

Clinical and radiographic outcomes of the modified McLaughlin procedure for locked posterior dislocation of the shoulder: a systematic review.

Background: Multiple treatment options for locked posterior dislocation of the shoulder (LPDS) have been described, including the modified McLaughlin procedure. The purpose of this review, therefore, was to perform a systematic review of the literature to synthesize the available data reporting on the clinical and radiographic outcomes of patients undergoing the modified McLaughlin procedure for the treatment of LPDS. Methods: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases from inception through January 2023 was performed. Outcomes studies reporting on clinical and radiographic outcomes in patients undergoing the modified McLaughlin procedure for LPDS were included. Postoperative complications and episodes of recurrent instability were noted. Results: A total of 1322 studies were initially identified, of which 9 were deemed eligible for inclusion in our review. Among included studies, a total of 97 shoulders (96 patients) with a mean age of 37.7 years (range, 26-51) were identified. The most common mechanisms of injury included trauma, seizure, and electrocution. Reverse Hill-Sachs lesions ranged in size from 20% to 50% of the humeral head articular surface. At final follow-up, the weighted mean University of California at Los Angeles shoulder score, Constant-Murley Score, American Shoulder and Elbow Surgeons shoulder score, and visual analog scale for pain score were 29 (range, 27-31), 75 (range, 65-92), 92 (range, 83-98), and 1.9 (range, 1-2.4), respectively. Postoperative Constant-Murley Score and University of California at Los Angeles scores were highest in the one study reporting exclusively on treatment during the acute period. Weighted mean postoperative forward flexion, abduction, external rotation, and internal rotation were 154° (range, 102-176), 144° (range, 118-171), 64° (range, 44-84), and 47° (range, 42-56), respectively. Osteointegration of the lesser tuberosity was noted in all patients at the final follow-up. Postoperative complications occurred in one patient (1.0% of cohort); a screw migration successfully treated with operative removal. Recurrent instability was noted in two epileptic patients (2.1% of cohort). Conclusion: The literature surrounding the use of the modified McLaughlin procedure for LPDS remains sparse. This review demonstrates that this procedure is associated with favorable clinical and radiographic outcomes with overall low rates of complication and recurrent instability, especially when the time from injury to surgery is minimized. These findings illustrate that in patients presenting with LPDS and a reverse Hill-Sachs lesion between 20% and 50% of the humeral head articular surface, the modified McLaughlin procedure is a safe and effective treatment option.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears. METHODS: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included. RESULTS: A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty. CONCLUSION: Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review.

BACKGROUND: When return to sport (RTS) at a competitive level is desired, treatment of injury to the ulnar collateral ligament (UCL) frequently involves surgical reconstruction. Although RTS rates between 66% and 98% have been reported, there remains a paucity of comparative clinical studies, with far fewer reporting statistically significant risk factors for reconstruction failure. The goal of this study was to perform a systematic review of the literature to demonstrate the variety and inconsistency with which risk factors associated with reconstruction failure are reported. MATERIALS AND METHODS: A systematic review of the PubMed Central and MEDLINE databases was performed to identify clinical outcome studies reporting ≥1 statistically significant risk factor associated with failure of UCL reconstruction. Failure was defined as (1) reinjury, recurrent instability, or need for revision surgery; (2) failure show improvement in postoperative patient-reported outcomes (PROs); or (3) failure to RTS at the preinjury level (RSL). RESULTS: A total of 349 unique studies were initially identified, of which 12 were deemed eligible for inclusion in our study. Of these 12 studies, 4 defined outcomes based on recurrent instability, reinjury, or revision surgery; 2 defined outcomes based on PROs; and 6 defined outcomes based on RSL. In the group with instability, reinjury, or revision failure, 11 significant risk factors were identified across all studies: age, height, body mass index, professional experience, injury to the nondominant arm, history of competitive throwing, mechanism of injury, history of a psychiatric diagnosis, presence of preoperative instability or stiffness, postoperative workload, and time to RTS. In the PRO failure group, 12 risk factors were identified across all studies: age, status as a military cadet, injury to the nondominant arm, graft type, baseball position, current injury to the ipsilateral arm, current level of competition attributed to reconstruction surgery, shoulder surgery after reconstruction, no competitive throwing history, non-throwing mechanism of injury, history of a psychiatric diagnosis, and preoperative instability or stiffness. In the RSL failure group, 4 risk factors were identified across all studies: age, ulnar neuritis, level of professional play, and amount of time spent at the professional level. CONCLUSIONS: Age, level of professional play prior to surgery, postoperative workload, and time at the professional level are the most commonly reported risk factors associated with UCL reconstruction failure. There remains a paucity of data associating risk factors with patient-specific outcomes and marked levels of inconsistency and conflict among the studies that report such data.

Isolated Osteochondral Autograft Versus Allograft Transplantation for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Systematic Review and Meta-analysis.

BACKGROUND: Focal cartilage lesions of the knee remain a difficult entity to treat. Current treatment options include arthroscopic debridement, microfracture, autograft or allograft osteochondral transplantation, and cell-based therapies such as autologous chondrocyte transplantation. Osteochondral transplantation techniques restore the normal topography of the condyles and provide mature hyaline cartilage in a single-stage procedure. However, clinical outcomes comparing autograft versus allograft techniques are scarce. PURPOSE: To perform a comprehensive systematic review and meta-analysis of high-quality studies to evaluate the results of osteochondral autograft and allograft transplantation for the treatment of symptomatic cartilage defects of the knee. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 2. METHODS: A comprehensive search of the literature was conducted using various databases. Inclusion criteria were level 1 or 2 original studies, studies with patients reporting knee cartilage injuries and chondral defects, mean follow-up ≥2 years, and studies focusing on osteochondral transplant techniques. Exclusion criteria were studies with nonknee chondral defects, studies reporting clinical outcomes of osteochondral autograft or allograft combined with other procedures, animal studies, cadaveric studies, non-English language studies, case reports, and reviews or editorials. Primary outcomes included patient-reported outcomes and failure rates associated with both techniques, and factors such as lesion size, age, sex, and the number of plugs transplanted were assessed. Metaregression using a mixed-effects model was utilized for meta-analyses. RESULTS: The search resulted in 20 included studies with 364 cases of osteochondral autograft and 272 cases of osteochondral allograft. Mean postoperative survival was 88.2% in the osteochondral autograft cohort as compared with 87.2% in the osteochondral allograft cohort at 5.4 and 5.2 years, respectively (P = .6605). Patient-reported outcomes improved by an average of 65.1% and 81.1% after osteochondral autograft and allograft, respectively (P = .0001). However, meta-analysis revealed no significant difference in patient-reported outcome percentage change between osteochondral autograft and allograft (P = .97) and a coefficient of 0.033 (95% CI, -1.91 to 1.98). Meta-analysis of the relative risk of graft failure after osteochondral autograft versus allograft showed no significant differences (P = .66) and a coefficient of 0.114 (95% CI, -0.46 to 0.69). Furthermore, the regression did not find other predictors (mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location) that may have significantly affected patient-reported outcome percentage change or postoperative failure between osteochondral autograft versus allograft. CONCLUSION: Osteochondral autograft and allograft result in favorable patient-reported outcomes and graft survival rates at medium-term follow-up. While predictors for outcomes such as mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location did not affect the comparison of the 2 cohorts, proper patient selection for either procedure remains paramount to the success and potentially long-term viability of the graft.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis.

BACKGROUND: Rotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA. AIM: To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA. METHODS: This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected. RESULTS: A total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes. CONCLUSION: Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Distal Biceps Repairs in Females: A Large Single-Center Case Series.

Background: Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown. Questions/Purpose: We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology. Methods: A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS). Results: Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20). Conclusion: This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Comparable Subjective and Objective Clinical Outcomes After Fibular or Combined Tibial-Fibular-based Reconstruction of the Posterolateral Corner of the Knee: A Systematic Review and Meta-analysis.

INTRODUCTION: To compare subjective and objective outcomes of fibular and combined tibial-fibular (TF)-based posterolateral corner (PLC) reconstruction. METHODS: A systematic review of literature reporting outcomes of posterolateral corner reconstruction was conducted including outcome studies of surgically treated PLC injuries with a minimum 1-year follow-up, postoperative subjective and objective outcomes including the patient-reported outcome scorings of Lysholm score, International Knee Documentation Committee evaluation (subjective and objective), dial test, and varus stress radiographs. RESULTS: The 32 studies included comprised 40 cohorts: 12 cohorts (n = 350 knees) used a fibular-based technique, and 28 cohorts (n = 593 knees) used a combined TF-based technique. No statistically significant differences were found in patient-reported outcomes or objective clinical measurements comparing the two techniques using the Lysholm score (P = 0.204, τ2 = 3.46), International Knee Documentation Committee evaluation (subjective P = 0.21 τ2 = 15.57; objective P = 0.398), dial test (P = 0.69), or varus stress radiographs (P = 0.98, τ2 = 0.08). CONCLUSIONS: This study found no statistically significant differences in subjective or objective clinical outcome measurements after fibular-based versus combined TF-based PLC reconstruction. Further prospective evaluation comparing long-term clinical outcomes, complications, and surgical time may help to elucidate a preferred reconstructive technique.

Clinical outcomes of a unique ulnar collateral ligament reconstruction hybrid technique with ulnar-sided suspensory fixation.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is the gold standard for treating ulnar collateral ligament injuries in throwing athletes who have failed conservative treatment. There are several described techniques that produce successful and reproducible outcomes. In addition, there is biomechanical evidence that supports hybrid fixation of the graft with a docking technique on the humeral side and suspensory fixation on the ulnar side. However, as of this writing there are no clinical studies that have reported results. This retrospective case series is the first of its kind to report on clinical outcomes following UCLR with hybrid suspensory fixation. METHODS: Fifty throwing athletes who underwent ULCR with hybrid suspensory fixation from 2010-2017 by one of 5 surgeons at a single institution were available at a median follow-up of 7 years. Return to sport, level of sport, and postoperative complications were recorded at final follow-up. RESULTS: A total of 50 patients were included in final analysis. Nearly all were able to return to sport at the same level or higher (48/50, 96%). One of these 50 athletes (2%) played professionally, 27 (54%) played collegiately, and 21 (42%) played at the high school level. Seven patients (14%) underwent reoperation following the index procedure. The median (interquartile range) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 0.098 (0-4.5) at final follow-up. CONCLUSION: Hybrid suspensory fixation is a safe and effective technique for UCLR in the throwing athlete. Throwers can expect to return to sport at a very high rate with low risks for postoperative complications.

Total Joint Arthroplasty and Golf Play: Analysis of Regional Golf Handicap Database.

BACKGROUND: As the numbers of senior golfers increase, many will consider a hip or knee joint replacement (JR) over their lifetime. The relationship of JR to the rate of return and validated level of play has not been well defined. METHODS: A regional golf association's membership was mailed a questionnaire regarding their JR. Members with valid Golf Handicap Information Network numbers and with at least five pre- and post-JR scores were included. Prospectively collected rounds of play and handicap differentials were used for the analysis. RESULTS: Two hundred fifty-one members reported having a JR, with 120 qualifying for the analysis. The sites of JR include 50 hips (41.7%) and 70 kness (58.3%). Plays per month after the first JR increased from 5.2 to 5.6 (P = 0.017). Handicap differentials increased from an average of 15.8 to 17.3 (P < 0.0001). Average return to play was 62 days. Twenty-eight players who had a second JR saw an increase in plays per month from 4.2 to 6.3 (P = 0.0074) and an increase in handicap differentials from 19.3 to 20.2 (P = 0.0036). CONCLUSIONS: After the initial JR, amateur golfers will likely play more frequently; however, the level of play will typically decrease slightly. The same effects are seen after a subsequent JR. LEVEL OF EVIDENCE: Level IV: retrospective, cross-sectional review.

Allograft Augmentation of Hamstring Autograft in Anterior Cruciate Ligament Reconstruction Results in Equivalent Outcomes to Autograft Alone.

PURPOSE: To examine allograft augmentation of undersized hamstring (HS) autograft tendons at the time of anterior cruciate ligament (ACL) reconstruction, compared with un-augmented autograft HS ACL reconstruction. METHODS: Patients who underwent ACL reconstruction at our institution between 2005 and 2015 were reviewed. Inclusion criteria included patients who underwent (1) primary ACL reconstruction, (2) use of a hybrid HS autograft with allograft augmentation, and (3) had a minimum 2-year postoperative follow-up. Patients with revision ACL, multiligamentous injuries, all-epiphyseal fixation techniques, or additional procedures beyond chondroplasty or meniscal repair/debridement were excluded. Data collected included demographics, graft size, concomitant procedures, revision operation, revision ACL reconstruction, and patient-reported outcomes. RESULTS: In total, 59 patients met criteria for inclusion into the hybrid group, and 80 patients were eligible for inclusion into the control group. The average age of the cohort was 22.9 (interquartile range Q1:17, Q3: 38.3), and 51.8% of the patients were female. Seven patients (11.9%) in the hybrid ACL group underwent revision ACL surgery versus 15 (18.8%) in the control group (P = .27). There was no difference in patient-reported outcomes between groups. CONCLUSIONS: Augmenting an HS ACL autograft that is 8 mm or less with allograft tissue to increase the overall size of the ACL graft shows no difference in overall reoperation or revision of ACL failure. The hybrid autograft/allograft ACL reconstruction patients showed no clinically important difference between groups in patient-reported outcome measures. LEVEL OF EVIDENCE: Level III, case-control comparative analysis.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND: Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation. RESULTS: In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness. CONCLUSION: We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Biomechanical Evaluation of an All-Inside Posterior Medial Meniscal Root Repair Technique Via Suture Fixation to the Posterior Cruciate Ligament.

PURPOSE: To evaluate the tibiofemoral contact mechanics of an all-inside posterior medial meniscal root repair technique via suture fixation to the posterior cruciate ligament (PCL) and to compare with that of the intact knee and the knee with a root tear. METHODS: Tibiofemoral contact mechanics were recorded in 8 human cadaveric knee specimens using pressure sensors. Each knee underwent 3 testing conditions related to the posterior medial meniscal root: (1) intact knee; (2) root tear; and (3) all-inside repair via suture fixation to the PCL. Knees were loaded with a 1000-N axial compressive force at 4 knee flexion angles (0°, 30°, 60°, 90°). Calculations were performed for contact area, mean contact pressure, and peak contact pressure. A generalized linear model with a Tukey adjusted least square means test was used to determine differences between testing conditions. RESULTS: Across all knee flexion angles, there was an overall mean 26.3% reduction in contact area with root tear (211.34 mm2 vs intact 286.64 mm2, P = .0002), and a 31.6% increase from root tear to repair (277.61 mm2, P = .0297). Across all knee flexion angles, there was an overall mean 24.3% increase in contact pressure with root tear (1849.12 N/mm2 vs. intact 1487.52 N/mm2, P < .0001), and a 31.1% decrease from root tear to repair (1410.7 N/mm2, P = .0037). Across all knee flexion angles, there was an overall mean 10.6% increase in peak contact pressure with root tear (4083.55 N/mm2 vs. intact 3693.68 N/mm2, P < .0001), and a 12.4% decrease from root tear to repair (3632.13 N/mm2, P = .531). CONCLUSIONS: In most testing conditions and with overall averaging across knee flexion angles, the all-inside posterior medial meniscal root repair with suture fixation to the adjacent PCL fibers restored contact area (from 26.3% reduction with root tear to 31.6% increase with repair), contact pressures (from 24.3% increase with root tear to 31.1% decrease with repair), and peak contact pressures (from 10.6% increase with root tear to 12.4% decrease with repair) to that of the intact knee This may be a future potential technique to limit complications associated with the traditional transtibial pull-out method of repair. CLINICAL RELEVANCE: This technique may provide a posterior medial meniscal root repair construct that restores most tibiofemoral contact mechanics and offers theoretical benefits of technical ease and potential for an acceptable, less "anatomic" repair location.

Return to sporting activity after ulnar nerve transposition for isolated neuritis in competitive overhead athletes.

BACKGROUND: Although ulnar neuritis can occur secondary to ulnar collateral ligament pathology, stress fractures, and traction apophysitis, isolated ulnar nerve dysfunction can lead to medial elbow pain. The purpose of this study was to evaluate the short-term outcomes of overhead athletes undergoing anterior ulnar nerve transposition for ulnar neuropathy. METHODS: All overhead athletes who underwent isolated ulnar nerve transposition between 2009 and 2016 for refractory ulnar neuritis were identified. The primary outcome was return to sport, and secondary outcome measures included the Kerlan-Jobe Orthopaedic Clinic score; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder and Hand score; Single Assessment Numeric Evaluation score; and visual analog scale score for pain. Complication and reoperation rates were recorded. RESULTS: A total of 26 overhead athletes (21 male and 5 female athletes) underwent ulnar nerve transposition at an average age of 18.4 years (range, 11-25 years). Of the patients, 24 (92%) returned to their sporting activity at an average of 2.7 months postoperatively, including 16 (62%) at the previous level of play. The average visual analog scale pain score improved from 4.7 (±2.5) to 0.4 (±1.5) (P = .015). The average postoperative patient-reported outcome scores were as follows: Kerlan-Jobe Orthopaedic Clinic score, 80 (95% confidence interval [CI], 72.7-87.0); Single Assessment Numeric Evaluation score, 85 (95% CI, 75.4-94.7); Quick Disabilities of the Arm, Shoulder and Hand score, 5 (95% CI, 2.1-7.7); and Mayo Elbow Performance Score, 91 (95% CI, 86.8-96.0). CONCLUSION: Cubital tunnel syndrome can cause medial elbow pain in overhead athletes in the presence of a normal ulnar collateral ligament. At mid-term follow-up, 92% of overhead athletes returned to sport after ulnar nerve transposition, with 62% resuming their previous level of performance.

Next-generation sequencing for diagnosis of infection: is more sensitive really better?

BACKGROUND: The utility of next-generation sequencing (NGS) in differentiating between active infection and contaminant or baseline flora remains unclear. The purpose of this study is to compare NGS with culture-based methods in primary shoulder arthroplasty. METHODS: A prospective series of primary shoulder arthroplasty patients with no history of infection or antibiotic use within 60 days of surgery was enrolled. All patients received standard perioperative antibiotics. After skin incision, a 10 × 3-mm sample of the medial skin edge was excised. A 2 × 2-cm synovial tissue biopsy was taken from the rotator interval after subscapularis takedown. Each sample set was halved and sent for NGS and standard cultures. RESULTS: Samples from 25 patients were analyzed. Standard aerobic/anaerobic cultures were positive in 10 skin samples (40%, 95% confidence interval [CI] 20%-60%) and 3 deep tissue samples (12%, 90% CI 1%-23%]). NGS detected ≥1 bacterial species in 17 of the skin samples (68%, 95% CI 49%-87%) and 7 deep tissue samples (28%, 95% CI 9%-47%). There was a significant difference (P < .03) in the mean number of bacterial species detected with NGS between the positive standard culture (1.6 species) and the negative standard culture groups (5.7 species). CONCLUSION: NGS identified bacteria at higher rates in skin and deep tissue samples than standard culture did in native, uninfected patients undergoing primary procedures. Further research is needed to determine which NGS results are clinically relevant and which are false positives before NGS can be reliably used in orthopedic cases.

The use of static external fixation for chronic instability of the elbow.

BACKGROUND: Chronic elbow instability after trauma is a challenging problem. Clinical results of external elbow fixation in this setting are limited, with most studies focusing on hinged external fixation. A static fixator is an alternative for maintaining joint reduction. Advantages of a static frame include ease of application, decreased need for special instrumentation, and more secure maintenance of a concentrically reduced joint in the setting of bone or soft tissue instability. The primary limitation of static fixation is the potential for stiffness. METHODS: This retrospective review represents the largest reported cohort evaluating the use of static elbow external fixation for the treatment of chronic elbow instability. Twenty-seven cases treated by a single surgeon between 2004 and 2015 were identified. RESULTS: Twenty patients were available for a clinical evaluation, including radiographs and a physical examination at a mean follow-up of 5.8 years (range, 1.4-12.4 years). Of note, 19 of 20 were clinically obese or overweight. At final evaluation, range of motion averaged from 20° ± 13° of extension to 134° ± 9° of flexion. All patients had stable elbows, except 1 patient who had valgus and varus laxity on stress examination. Radiographs of this patient showed an incongruous joint. Eight patients required an additional operation after external fixator removal, 3 for infection and 5 for stiffness. CONCLUSIONS: At almost 6 years of follow-up, static elbow external fixator resulted in a congruous joint with adequate functional and clinical outcomes in 95% of patients.

Patient Preferences and Utilization of Online Resources for Patients Treated in Hand Surgery Practices.

BACKGROUND: The Internet is a widely used resource by patients however, objective data on details such as frequency of usage and specific sites visited is lacking. We surveyed patients from hand surgery practices to describe patient preferences and utilization patterns for online resources. METHODS: From October 2015 to June 2016, we enrolled patients presenting to 4 orthopedic hand surgeons at 2 academic institutions. Patients completed a survey, with questions related to their preference for learning about their diagnosis and Internet utilization both before and after the visit. RESULTS: A total of 226 patients were enrolled in the study. Forty-five percent of the patients had done online research prior to the office visit, and 81% preferred to learn about their diagnosis through verbal communication, as opposed to only 8% who listed Web site information. Fifty percent indicated that there was a greater than 50% chance or they would definitely seek additional information on the Internet after the office visit. When asked to choose from a list of Web sites to visit, the most popular Web site was WebMD. Specialty society Web sites (American Society for Surgery of the Hand and American Academy of Orthopaedic Surgeons) were less popular. CONCLUSIONS: This survey-based study found that a majority of patients utilize the Internet both before and after the office visit; however, they often utilize unregulated sites for information. This information can help physicians guide patients to high-quality Web sites for information on their clinical diagnosis and treatment.

Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty.

BACKGROUND: Propionibacterium acnes (P. acnes) is the most common bacteria associated with infection after shoulder arthroplasty. These bacteria can be grown on culture of skin after standard preoperative skin preparation and antibiotics. The purpose of this study was to determine whether adding preoperative intravenous doxycycline reduces the prevalence of positive P. acnes cultures of skin and deep tissues at the time of prosthetic joint implantation during shoulder arthroplasty. METHODS: This was a randomized controlled trial. An a priori power analysis determined that a sample size of 56 patients was necessary. Patients scheduled to undergo shoulder arthroplasty were randomized to receive either standard perioperative cefazolin or a combination of doxycycline and cefazolin. Tissue specimens for culture were then taken from the skin edge, and swabs of the superficial dermal tissue and glenohumeral joint were obtained. All cultures were maintained for 14 days to allow for P. acnes detection. Groups were compared to determine if the addition of doxycycline reduced the rate of culture positivity. RESULTS: Fifty-six patients were enrolled and randomized. Twenty-one (38%) had ≥1 positive cultures for P. acnes, with no significant difference between the group treated with cefazolin alone (10 [37%] of 27 patients) and the combined doxycycline and cefazolin group (11 [38%] of 29 patients) (p = 0.99). The greatest numbers of culture-positive samples were obtained from the skin (30%), followed by dermal tissue (20%) and the glenohumeral joint (5%). Patients who had ≥1 positive cultures were younger than those who did not (mean age [and standard deviation], 64.9 ± 7.7 versus 69.4 ± 7.7 years; p = 0.041), had a greater tendency to be male (16 [76%] of 21 versus 17 [49%] of 35; p = 0.053), and had a lower Charlson Comorbidity Index (3.35 ± 1.3 versus 4.09 ± 1.4; p = 0.051). There were no significant differences between the culture-positive and culture-negative groups in terms of body mass index (BMI) (p = 0.446) or arthroplasty type, with positive cultures found for 8 of the 29 anatomic shoulder arthroplasty procedures compared with 13 of the 27 reverse shoulder arthroplasty procedures (p = 0.280). There were no doxycycline-related adverse events. CONCLUSIONS: In this randomized controlled trial, doxycycline did not significantly decrease P. acnes culture positivity of the skin, dermis, or glenohumeral joint of patients undergoing shoulder arthroplasty. The addition of prophylactic intravenous antibiotics to cover P. acnes may not be an effective method to reduce postoperative and periprosthetic shoulder joint infections. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Fixation of proximal pole scaphoid nonunion with non-vascularized cancellous autograft.

We present 20 patients with established proximal pole scaphoid nonunions treated with curettage and cancellous autograft from the distal radius and screw fixation. Fractures with significant proximal pole fragmentation were excluded. Patients were treated at a mean of 26 weeks after injury (range 12-72). Union occurred in 18 of 20 patients (90%) based on computed tomographic imaging. The two nonunions that did not heal were treated with repeat curettage and debridement and iliac crest bone grafting without revision of fixation. Union was achieved in both at a mean of 11 weeks after the revision procedures. Our findings suggest that non-vascularized cancellous autograft and antegrade fixation is a useful option for the treatment of proximal pole scaphoid nonunions. LEVEL OF EVIDENCE: IV.