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[This corrects the article DOI: 10.1016/j.jseint.2025.05.006.].
Robot-assisted colorectal surgery (RAS) is increasingly adopted; however, surgeon workload during supervised training and its determinants remain unclear. We conducted a single-center study combining a prospective surgical task load index (Surgical-TLX) assessment and a retrospective cohort analysis (October 2023-August 2025). Junior surgeons were defined as non-Japan Society for Endoscopic Surgery (JSES)-certified surgeons who had < 10 robot-assisted colorectal cases as the primary operator and were within 8 years after graduation. All junior cases were performed under direct supervision by JSES-certified surgeons throughout the procedure. The primary outcome was Surgical-TLX workload (six domains). Secondary outcomes included operative time, console time, blood loss, Clavien-Dindo complications, length of stay, and pathological findings. Surgical-TLX was assessed in 72 cases by 10 surgeons. Compared with JSES-certified surgeons, junior surgeons had higher mental, temporal, task complexity, and situational awareness workload. In multivariable models, high temporal burden was associated with advanced tumor factors (T ≥ 3 and N-positive disease). Operative and console times were longer for junior surgeons, whereas blood loss, postoperative complications (Clavien-Dindo ≥ 2 or ≥ 3), length of stay, and pathological outcomes were comparable. Under structured supervision, RAS can be implemented safely for junior surgeons despite higher perceived workload. Surgical-TLX may help visualize cognitive burden and inform graded autonomy and supervisory strategies, particularly for advanced tumors.
The incidence of acute prosthetic joint infections (PJIs) that develop within one year following aseptic revision total shoulder arthroplasty (TSA) has been poorly described. The purpose of this study was to identify the rate of PJI following aseptic revision TSA. A retrospective cohort study was performed of patients who underwent aseptic revision TSA identified by Current Procedural Terminology codes 23473 and 23474 at a single academic institution between 2015 and 2022. Only patients with negative intraoperative cultures held for a minimum of 14 days were included. Patients were followed for one year postoperatively to identify acute periprosthetic joint infections, which were classified using the 2018 International Consensus Meeting shoulder-specific criteria. Demographic, perioperative, and clinical variables were compared between infected and noninfected cohorts. Overall, 140 patients met the inclusion criteria. Of these, 7 developed an acute PJI (5.0% infection rate). There was no statistical difference in patient age (64.9 vs. 69.0; P = .29), body mass index (30.4 vs. 31.0; P = .75), male sex (71% vs. 40%; P = .10), or smoking history (71% vs. 45%; P = .19) between the infected and noninfected cohorts. Aseptic revision TSA was found to have a 5.0% rate of acute PJIs within the first year postoperatively. There was no significant difference in age, body mass index, gender, history of tobacco use, underlying comorbidities, length of operative time, or length of hospitalization between patients who developed acute PJI and those who did not.
Rotator cuff disease constitutes the most common cause of shoulder pain, accounting for up to 70% of shoulder-related complaints, with partial-thickness rotator cuff tears (PT-RCTs) representing a substantial proportion. Although nonsurgical interventions are generally recommended as first-line treatment, there is currently no consensus on the optimal nonsurgical management of symptomatic PT-RCTs. This study aims to determine the effectiveness of different nonsurgical treatment modalities for PT-RCTs, specifically comparing physical therapy (PT) and injection therapies. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. Eligible studies on nonsurgical interventions for PT-RCTs in adults (≥18a) were included. Clinical outcomes (Constant Score (CS), American Shoulder and Elbow Surgeon (ASES) score, and visual analog scale were analyzed using random-effects meta-analysis and descriptive statistics to outline study characteristics. From 9,894 records screened, 22 studies with 1,137 patients were included. PT was statistically superior to injection therapy in the CS (P = .0001). Among injections, cell-based therapies outperformed non-cell-based injections in the CS (P = .01) and exceeded Minimally Clinically Important Difference (MCID) for both the CS and ASES, indicating both statistical and clinical significance. Non-cell-based injections and PT show statistical significance in the CS (P < .001), with intervention groups outperforming control groups. Non-cell-based injections also surpass the clinical threshold in the CS (mean difference = 19.11), showing both statistical and clinical significance. In PT-RCTs, PT shows statistically superior outcomes to injection therapy in the CS. Cell-based injections outperform non-cell-based injections in the CS and exceed MCID in both, the CS and ASES scores, indicating clinical relevance. Both experimental groups for non-cell-based injections and PT show statistical significance in the CS, with non-cell-based injections surpassing the MCID in the CS. These findings highlight the effectiveness of PT and cell-based injections as nonsurgical options, but treatment should be individualized, as no single approach proved clearly superior across all outcomes.
Regional variations in surgical training may influence where physicians establish clinical practice. In the competitive field of shoulder and elbow surgery, the impact of training location on practice patterns remains unclear. As shoulder arthroplasty volumes continue to rise and rotator cuff disease remains a common musculoskeletal complaint among older patients, equitable access to trained shoulder specialists is paramount. A deeper understanding of these trends may help identify regions that better train and retain subspecialists and inform strategies to improve geographic and gender representation. This study included shoulder and elbow surgeons identified through the American Shoulder and Elbow Surgeons database. Training and practice locations-medical school, residency, fellowship, and current employment were categorized using U.S. Census regions (Northeast, South, Midwest, West, international). Residency programs were also ranked according to the top 25 orthopedic hospitals listed in U.S. News & World Report. Publicly available sources were used to collect demographic and professional data. Descriptive statistics and chi-square analyses assessed geographic retention, and subgroup analyses evaluated differences by gender. A total of 752 shoulder and elbow surgeons were identified: 50 (6.6%) were female and 702 (93.4%) were male. Surgeons were significantly more likely to practice in the same region where they completed residency (range: 44.1%-77.0%, P < .001), medical school (36.8%-70.4%, P < .001), and to a lesser extent, fellowship (21.9%-68.7%, P < .001). In the Northeast, retention following residency (77.0%) and fellowship (68.7%) was especially high (P < .001). In contrast, fellowship retention in the Midwest was the lowest (21.9%, P = .002). Female surgeons were more likely to remain in the Northeast after fellowship (32.0% vs. 20.2% for males, P = .048). In comparison, male surgeons were significantly more likely to remain in the Midwest after residency (10.5% vs. 0%, P = .016). Female representation was highest in the Northeast (9.1%) and lowest in the West (0.7%), though these regional differences did not reach statistical significance (P > .05). Geographic retention among shoulder and elbow surgeons was highest following residency and medical school and lowest after fellowship, where retention varied widely by region. The Northeast consistently demonstrated the highest retention across training stages, whereas the Midwest had the lowest retention after fellowship. Sex-based differences were also observed, with greater retention of female surgeons in the Northeast after fellowship and no female retention in the Midwest after residency. These findings highlight consistent regional and sex-based differences in geographic retention across training stages.
Reverse total shoulder arthroplasty (rTSA) reliably reduces pain and restores function, but shoulder function typically plateaus within the first post-operative year and gradually declines thereafter. Motion-triggered functional electromyostimulation (FES) enhances muscle activation and has shown short-term functional benefits in patients after rTSA. The long-term durability of these effects remains unclear, though sustained improvements would increase the clinical value of this time-limited intervention. Therefore, the aim of this study was to evaluate short-term outcomes after at least six months after completion of a FES program and compare them with baseline and immediate postintervention results. Ten of the initially 14 patients previously enrolled in the intervention arm of a prospective randomized controlled trial were re-evaluated after at least six months after completing a 6-week home-based, deltoid-focused FES program initiated 1 year after primary rTSA. Clinical outcomes included Constant Score (primary outcome), Subjective Shoulder Value, active range of motion, deltoid strength, and scapular kinematics assessed using identical methods to the previous randomized controlled trial. Ten participants (71%) completed the follow-up (FU) at a median of 18 months (range, 6-24 months) after the intervention. The mean Constant Score improved from 65.7 ± 13.2 at baseline to 79.5 ± 7.9 postintervention (P < .001) and remained significantly elevated at FU (84.0 ± 4.2, P < .001 vs. baseline; P = .09 vs. post). Subjective Shoulder Value increased from 70.7 ± 16.9% to 91.1 ± 10.0% postintervention and was maintained at 92.0 ± 7.9% at FU (P < .001 vs. baseline). Abduction range of motion and deltoid strength showed additional long-term gains, whereas no decline was observed in any outcome parameter. No device-related complications occurred. In this single-arm FU, functional outcomes that improved after the FES-augmented program were maintained at mid-term reassessment. Because the control group was not re-evaluated, treatment-specific durability cannot be inferred. No deterioration was observed after discontinuation of device use. Larger controlled studies with long-term comparative FU are required before conclusions regarding treatment-specific benefit can be drawn.
There is no consensus regarding the pathologic significance of effusion within the long head of the biceps tendon sheath (LHB effusion), and its association with other shoulder joint pathologies remains unclear. We hypothesized that establishing a quantitative evaluation method for LHB effusion and defining pathologic effusion on magnetic resonance imaging (MRI) would help clarify the relationship between LHB effusion and other pathologic shoulder conditions. The purpose of this study was to establish a quantitative MRI-based threshold for pathologic LHB effusion and to investigate its associations with clinically relevant shoulder pathologies. We retrospectively reviewed 261 shoulder MRI examinations acquired between July 2019 and December 2020. The LHB effusion area was evaluated on axial T2∗-weighted MRI images. A shoulder surgeon and a musculoskeletal radiologist also independently judged whether LHB effusion was physiological or pathologic. A receiver operating characteristic curve was generated based on their judgments and the measured effusion areas, and the threshold value for pathologic LHB effusion area was determined. Other shoulder joint pathologies, including fatty infiltration of the rotator cuff muscles, supraspinatus tendon tear, subscapularis tendon tear, frozen shoulder, and LHB lesion, were assessed using MRI, and their associations with pathologic LHB effusion were analyzed using univariate and multivariate analyses. The threshold values for pathologic LHB effusion area, determined based on the expert visual assessment of the shoulder surgeon and the musculoskeletal radiologist, were 18.13 and 19.29 mm2, respectively. When an LHB effusion area of ≥19 mm2 was defined as pathologic, univariate analysis showed that pathologic LHB effusion was associated with LHB lesion, frozen shoulder, subscapularis tendon tear, and older age. Multivariate analysis showed that pathologic LHB effusion was associated with LHB lesion (odds ratio [OR], 4.370; P < .01), frozen shoulder (OR, 3.16; P < .01), and older age (OR, 1.03; P = .01). Quantitative MRI assessment of LHB sheath effusion demonstrated high measurement reproducibility, and an expert-derived threshold of approximately 19 mm2 was associated with older age, LHB lesions, and frozen shoulder. Because the threshold was derived from expert visual assessment rather than an independent pathologic gold standard, these findings should be considered preliminary and require external validation before use as a diagnostic criterion.
Informed consent for reverse total shoulder arthroplasty (rTSA) requires thorough patient understanding, yet only 29% of patients adequately comprehend pre-operative information. This study evaluated whether pre-operative educational videos enhance patient comprehension compared to standard verbal explanations alone and assessed impact on consultation time and demographic variations. This prospective randomized controlled trial included 60 patients undergoing rTSA, assigned 1:1 to video education or control groups. The video group viewed a 2-minute explanatory video before informed consent discussion; the control group received only verbal discussion. Afterward, all participants completed a 7-question test on procedural knowledge, benefits, and risks. The video education group achieved significantly higher scores (5.70/7) compared to controls (4.67/7) (P = .002). Significant improvements were observed across all subgroups. Vulnerable subgroups, including older (P = .02), lower-educated (P = .007) participants, and non-native speakers (P = .04), also demonstrated benefit. An explanatory video before informed consent discussion significantly improved procedural comprehension compared to standard discussion alone. Vulnerable subgroups, older participants, non-native speakers, and those with lower educational attainment showed particular benefit. These findings support integrating video education into standard pre-operative rTSA protocols.
Management of large to massive rotator cuff tears (RCTs) remains challenging, particularly when complete anatomic repair is not feasible. The current study aims to evaluate short-term clinical outcomes and complications following arthroscopic partial repair of large to massive RCT with incomplete footprint coverage and to compare outcomes according to concomitant subscapularis repair and post-operative rotator cuff integrity. Patients who underwent arthroscopic partial repair of the supraspinatus tendon, with or without associated infraspinatus tears, and incomplete footprint coverage between July 2022 and April 2023 were retrospectively identified. Inclusion criteria included intraoperative confirmation of incomplete anatomic footprint coverage, an anteroposterior tear size ≥ 3 cm, and the presence of either an intact subscapularis tendon or a reparable concomitant subscapularis tear (Lafosse type ≤3). Patients were excluded if they were lost to follow-up, had a history of prior shoulder instability surgery, or had insufficient clinical or radiologic data. Clinical outcomes were evaluated pre-operatively and at final follow-up using the visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, active range of motion (ROM), and shoulder strength. Radiologic assessment included evaluation of repair integrity, acromiohumeral distance, and progression of glenohumeral arthritis. After excluding 15 patients, 142 patients were included in the final analysis. At a mean follow-up of 26.2 months, significant improvements were observed in all pain, patient-reported outcome measures, ROM, and strength (all P < .001). Post-operative retear was identified in 43 patients (30.3%). Clinical outcomes did not differ significantly between patients with intact subscapularis tendons and those who underwent concomitant subscapularis repair. However, patients with intact post-operative repair integrity demonstrated significantly superior pain relief, functional scores, ROM, and strength compared with those who experienced retears (all P < .001). Arthroscopic partial repair with incomplete footprint coverage was associated with significant short-term improvements in pain, function, ROM, and strength in patients with large to massive RCT. Outcomes were similar between patients with intact subscapularis tendons and those undergoing concomitant repair of reparable subscapularis tears. However, post-operative structural failure occurred in 30.3% of patients and was associated with inferior outcomes and frequent revision surgery. These findings should be interpreted cautiously given the retrospective design, absence of a comparator group, and short-term follow-up.
Posterior superior irreparable rotator cuff tears (PSIRCTs) cause substantial functional limitations, particularly in individuals performing physically demanding work or participating in sports. The purpose of this study was to evaluate the rate and timing of return to work (RTW) and return to sports (RTS) following posterior latissimus dorsi (LD) transfer in patients with PSIRCTs and to identify factors associated with successful return. It was hypothesized that patients would demonstrate high RTW and RTS rates. This retrospective study included patients who underwent posterior LD transfer for PSIRCTs between April 2012 and June 2020. RTW and RTS rates, timing, and levels of return were assessed using structured questionnaires. Clinical outcomes, including visual analog scale, American Shoulder and Elbow Surgeons, Constant, and Single Assessment Numeric Evaluation scores, as well as active range of motion (ROM), were evaluated pre-operatively and post-operatively. Multivariable analysis was used to identify factors associated with RTW and RTS. Patients who had undergone revision surgery, were lost to follow-up, or had unavailable clinical or radiological data were excluded. After excluding 15 patients, 83 patients were included (mean age 61.9 ± 5.3 years; mean follow-up 65.3 ± 13.9 months). Pre-operative occupational demand was classified according to the Dictionary of Occupational Titles criteria as light, medium, or heavy work based on physical workload requirements. Overall, 85.5% of patients returned to work, including 56.6% at their previous work level and 28.9% at a reduced level, while 14.4% did not return. In subgroup analysis, patients with lighter workloads demonstrated higher RTW rates (95.2% vs. 92.3% vs. 75.0%) and shorter return times (4.1 ± 1.1 vs. 4.1 ± 1.2 vs. 5.6 ± 1.6 months) compared with those performing heavy labor. The overall RTS rate was 89.7%, with 72.1% achieving complete RTS and 27.8% partial RTS. On multivariable analysis, higher work intensity and tendon retear were significantly associated with RTW, whereas tendon retear was the only significant predictor of RTS. Posterior LD transfer for PSIRCTs was associated with high rates of RTW and RTS among patients without major post-operative failure. Higher occupational demand was associated with delayed and less complete RTW, while tendon integrity was associated with both RTW and RTS. These findings should be interpreted cautiously because of retrospective design, self-reported activity outcomes, limited subgroup sizes, and exclusion of patients requiring revision surgery or conversion to reverse shoulder arthroplasty.
Heterotopic ossification (HO) is a recognized complication following operative fixation of elbow trauma. While indomethacin prophylaxis is well established in hip and acetabular surgery, evidence for its role in elbow injuries remains limited. This randomized controlled trial evaluated whether oral indomethacin reduces the incidence and severity of HO after surgical treatment of acute elbow fractures and dislocations. Eighty-six adults with acute elbow injuries requiring surgical fixation were randomized 1:1 to receive either oral indomethacin (25 mg 3 times daily for three weeks) or no prophylaxis. Eighty-four patients completed follow-up. HO was assessed radiographically at scheduled intervals through the final follow-up and graded using the Hastings and Graham system. The Mantel-Haenszel method was used to calculate a pooled odds ratio adjusted for injury severity. HO developed in 21 of 84 patients (25%), occurring in 14.3% of the indomethacin group vs. 35.7% of controls (P = .018), with indomethacin reducing both incidence (absolute risk reduction 21.4%; number needed to treat = 5) and severity (mean grade, 1.33 vs. 2.93, P = .013). All HO in the indomethacin group were low grade (G1-G2A), whereas high-grade HO (G2C-G3) occurred in 8 of 15 (53.3%) control patients. Stratified analysis demonstrated consistent trends across injury severity levels, with Mantel-Haenszel adjustment yielding similar estimates. Patients with HO in the indomethacin group had a greater range of motion compared to controls. Indomethacin prophylaxis was associated with reduced incidence and severity of HO following operative fixation of elbow injuries. These findings should be interpreted in the context of baseline differences in injury severity between groups. Indomethacin may be a useful adjunct in patients at risk of HO following elbow trauma given its low cost, ease of administration and favorable safety profile, although further multicenter studies are required.
Glenoid loosening is a well-documented failure mechanism in anatomic shoulder arthroplasty. Implant manufacturers have developed innovative designs to address these issues, with hybrid glenoid components emerging as a potential solution. This study investigates the Exactech Equinoxe glenoid (Exactech Inc., Gainesville, FL, USA), a hybrid component that has shown higher midterm revision rates in national registry data. We conducted an investigation of failed Equinoxe Cage Glenoid implants revised between November 2022 and July 2025 and analyzed at a tertiary arthroplasty retrieval center. Clinical data, radiographs, and intraoperative findings were reviewed. Radiographs were assessed for radiolucency (Lazarus score), implant position, and evidence of fracture or metallic debris. Retrieved components underwent macroscopic inspection and evaluation of wear modes. Polyethylene (PE) oxidation was quantified through white-banding assessment and Fourier Transform Infrared Spectroscopy. Periprosthetic tissues, when available, underwent inductively coupled plasma mass spectrometry to evaluate metal ion presence. Eleven failed hybrid glenoid components were analyzed at a median of 5.8 years after implantation. Radiographic loosening was present in 82% of cases (median Lazarus score 5). All retrieved components demonstrated macroscopic PE wear; 82% showed cracking and delamination. Fourier Transform Infrared Spectroscopy confirmed subsurface oxidation in all tested components. Peripheral peg fixation was limited, with 100% of pegs demonstrating minimal bony ongrowth and 45% showing polishing consistent with micromotion. In contrast, 100% of central metal cages exhibited bony ingrowth. Metal debris or staining was noted in 55% of cases, and tissue samples demonstrated elevated metal ions consistent with cage or peg wear. Failed Equinoxe Cage Glenoid implants demonstrated consistent patterns of PE oxidation and inadequate peripheral peg fixation, contributing to loosening and mechanical failure at the PE-metal interface. These findings provide a potential mechanism for the higher revision rate observed in national registry data and highlight the importance of ongoing postmarket surveillance of new implant designs.
The biomechanics of reverse shoulder arthroplasty (RSA) rely on deltoid function. The center of rotation of the glenohumeral joint in RSA is more medial and distal when compared to the native joint, and proper soft-tissue tensioning is essential to achieve a stable joint with a good range of motion (ROM). The current RSA systems on the market allow for various placements of humeral and glenoid components (lateralized, medialized, distalized). No post-operative radiographic parameters currently consider the glenoid and humeral components' position separately. The aims of this study are to (1) measure glenoid and humeral component angles specific to different implants and (2) to investigate whether these angles correlate with clinical outcomes. A retrospective analysis of 74 patients who underwent reverse shoulder prosthesis between 2018 and 2022 was performed. Different subtypes of RSA prosthesis were identified (medialized glenoid/lateralized humerus, lateralized glenoid/medialized humerus, and lateralized glenoid/lateralized humerus). Angle measurements were defined to determine the lateralization and distalization of each component in true anteroposterior radiographs (Grashey view) of the shoulder. The clinical results were collected, including a Simple Shoulder est, Single Assessment Numeric Evaluation, and Constant score. All angles showed excellent intra-rater and inter-rater agreement. No correlation was found between ROM and post-operative radiographic measurements, and there were no significant differences between the different RSA subtypes in clinical outcomes. The main objectives to be met are the post-operative scores, ROM, and patient satisfaction after RSA; however, there are still no reliable measures in post-operative radiographs that correlate with clinical outcomes. The current angles obtained on post-operative radiographs allow us to assess the prosthesis's placement degree due to each of the components but not to predict ROM or clinical outcomes.
This study evaluated the influence of stem global lateralization on tuberosity consolidation and functional outcomes in patients undergoing reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures (PHFs). A retrospective, two-institution study included patients who underwent rTSA for acute PHFs implanted with one of 3 stems: the Arrow (global lateralization 21.4 mm), the Humelock II (11.2 mm), or the Unique (14.7 mm). Stems were classified as very highly lateralized (VHL; >20 mm, Arrow) or lateralized (L; 10-15 mm, Unique and Humelock II). Tuberosity consolidation was assessed radiographically at a minimum 12-month follow-up. Functional outcomes included forward flexion, external rotation, visual analog scale pain, and Constant Murley score (CS). The lateralization shoulder angle (LSA) and distalization shoulder angle were measured and compared across groups. Complication and reoperation rates were recorded. A total of 113 patients were included: Arrow (N = 53), Humelock II (N = 40), and Unique (N = 20), comprising 53 in the VHL group and 60 in the L group. The overall consolidation rate was 82.1%. Nonunion rates differed significantly across stems (P = .018): 24.5% for the Arrow, 10.0% for the Humelock II, and 0% for the Unique, with a significant dose-response trend between increasing lateralization and increasing nonunion rate (P = .022). Patients achieving consolidation demonstrated significantly better forward flexion, external rotation, CS, and visual analog scale pain than those with nonunion (P < .05). Even among consolidated patients, the VHL group demonstrated significantly lower forward flexion, higher pain scores, and lower CS than the L group (P < .05). LSA values were similar across all consolidated groups despite a nearly 10 mm difference in global lateralization (P = .112). A significant dose-response relationship between increasing stem lateralization and tuberosity nonunion rate was observed, with functional consequences extending beyond nonunion alone. Post-operative LSA does not reliably reflect the local mechanical environment at the tuberosity-implant interface. These findings identify proximal stem lateralization as a potentially important modifiable determinant of outcomes after fracture rTSA and underscore the need for prospective studies to define the threshold of lateralization compatible with reliable tuberosity healing.
The Latarjet procedure is a well-established surgical technique for treating anterior shoulder instability. However, concerns remain regarding its long-term effects on subscapularis muscle integrity and glenohumeral joint health, particularly when using an inverted L-shaped tenotomy. This study aimed to evaluate subscapularis fatty infiltration and function, glenohumeral osteoarthritis, and bone graft osteointegration after a minimum 10-year follow-up. This prospective study included 32 patients who underwent the Latarjet procedure with an inverted L-shaped subscapularis tenotomy and single-screw coracoid fixation before January 2014. Functional outcomes were assessed using the Rowe and Constant Murley scores (CMS), subscapularis-specific strength testing, and internal rotation strength measured with a dynamometer. Magnetic resonance imaging was used to assess subscapularis fatty infiltration according to the Goutallier classification, while glenohumeral osteoarthritis was graded on X-ray using the Samilson-Prieto classification. At final follow-up, 78.3% of patients achieved Rowe scores of good to excellent, and the mean Constant Murley scores was 94 ± 5.9. The mean subscapularis strength was 5 of 5 on the Medical Research Council scale in more than 90% of the patients, with an average internal rotation strength of 7.4 kg. Fatty infiltration of the subscapularis was classified as Goutallier grade 2 or 3 in 21.9% of cases. Glenohumeral osteoarthritis was identified in two-thirds of patients; however, 50% of these cases were classified as mild (grade 1). Complete graft osteointegration was observed in all cases. The Latarjet procedure with an inverted L-shaped subscapularis tenotomy provides satisfactory long-term clinical and radiological outcomes, with preservation of subscapularis function and limited fatty infiltration. These findings suggest that this approach represents a viable surgical option for anterior shoulder instability; however, no direct comparison was performed, and results should be interpreted in light of the study limitations.
Selective serotonin re-uptake inhibitors (SSRIs) and serotonin-norepinephrine re-uptake inhibitors (SNRIs) are commonly prescribed medications for depression, anxiety, and other comorbid psychiatric conditions. However, these medications can have off-target effects, such as lowering platelet serotonin levels and reducing the ability of platelets to aggregate, which may lead to higher rates of post-operative bleeding. The aim of this paper was to determine if SSRIs/SNRIs increase the risk of post-operative hematoma formation following traumatic elbow surgery. Adult patients who underwent elbow fracture surgery between 2009 and 2022 were reviewed retrospectively utilizing a national administrative claims database. Exclusion criteria included patients who sustained a pathological fracture, open fracture, had an active infection, or hematologic disorder at the time of surgery. Patients were divided into those who were not prescribed SSRIs/SNRIs (control) and those prescribed SSRIs/SNRIs within 90 days pre-operatively (treatment). Patient cohorts were then propensity-score matched in a 1:3 ratio. Multivariable logistic regression was performed to assess 30- and 90-day outcomes. Over 6,000 patients were included in the initial query. After propensity-score matching, 985 patients were included in the control group (no SSRI/SNRI) and 2,494 patients in the treatment (SSRI/SNRI) group. At 30 days post-operatively, patients in the treatment group had a significantly greater rate of Surgical Site Infection (SSI) (3.4% vs. 2.2%; P = .04). There was no significant difference in rates of 30-day hematomas between the 2 cohorts. At 90 days post-operatively, there was a statistically significant difference in complications for patients treated with SSRI/SNRIs, including a higher rate of SSI (5.4% vs. 3.3%; P = .01) and hematoma formation (1.2% vs. 0.6%; P = .04). SSRIs and SNRIs are commonly prescribed to patients for a variety of psychiatric conditions. These medications often go unnoticed in the pre-operative surgical assessment; however, this retrospective study suggests an association between SSRI/SNRI use and higher odds of SSI and hematoma formation.
Glenoid bone mineral density (BMD) has important implications for the fixation of glenoid components and may vary based on indications for reverse total shoulder arthroplasty (rTSA).17 Careful consideration of pre-operative bone quality can enable surgeons to improve pre-operative and intraoperative decision-making for glenoid component fixation and reduce associated complications, such as aseptic loosening. There remains a paucity of literature exploring such implications in rTSA. We hypothesize that BMD varies by indication diagnosis for rTSA. A retrospective chart review was conducted on patients receiving an rTSA from a single surgeon from March 2021-May 2024 with one of the 3 following diagnoses: proximal humerus fracture (FX), glenohumeral osteoarthritis (GHOA), and rotator cuff arthropathy (RCA). Pre-operative computerized tomography scans were analyzed for glenoid BMD. Differences in BMDs across different shoulder pathologies were assessed with general linear regression models adjusted for age and body mass index. In sum, 150 patients were identified who underwent an rTSA for one of the 3 following diagnoses: FX (n = 24, 16%), GHOA (n = 64, 43%), and RCA (n = 62, 41%). Fifty-one (34%) of patients were male and 99 (66%) of patients were female. Average subchondral BMD was 150 Hounsfield Units (HUs) (95% confidence interval of 92-207 HUs) for FX, 304 HUs (268-339 HUs) for GHOA, and 208 HUs (172-244 HUs) for RCA. Subchondral bone in patients with GHOA was significantly denser than FX and RCA (P < .01). Average anterior cortex bone density was 1,206 HUs (113-1,299 HUs), 1,262 HUs (1,205-1,319 HUs), and 1,198 HUs (1,140-1,256 HUs) for FX, GHOA, and RCA patients, respectively. No statistically significant differences in anterior cortical HU were observed across the 3 pathologies in this study. Average posterior cortex bone density was 876 HUs (763-990 HUs), 969 HUs (889-1,038 HUs), and 959 (888-1,030 HUs) for FX, GHOA, and RCA patients, respectively. No statistically significant differences in posterior cortical HUs were observed across the 3 pathologies in this study. This study demonstrates that subchondral glenoid BMD varies among patients undergoing rTSA depending on the underlying pathology. Fracture rTSAs have the lowest subchondral BMD when compared to GHOA and RCA patients. BMD of the anterior cortex appears equivalent despite indication for rTSA. Incorporating glenoid BMD assessments into surgical planning may enhance implant fixation and possibly avoid complications such as implant loosening. Further prospective studies are warranted to validate and refine clinical decision-making based on glenoid bone quality.
Although reverse total shoulder arthroplasty (rTSA) can restore shoulder function in patients with rotator cuff deficiency, it relies heavily on the deltoid muscle. Low muscle volume, particularly in rheumatoid arthritis (RA), may lead to suboptimal outcomes. The purpose of this study was to investigate the relationship between pre-operative deltoid muscle volume and post-operative range of shoulder elevation, focusing on the influence of pre-operative joint stiffness. We retrospectively reviewed 45 consecutive patients (49 shoulders) with RA or cuff tear arthropathy (CTA) who underwent rTSA. The mean follow-up period was 30 months. Active and passive range of motion were evaluated pre-operatively and post-operatively. Pre-operative deltoid cross-sectional area was measured on magnetic resonance imaging to calculate the "deltoid index" (area [mm2]/height2 [m2]). Correlations between the deltoid index and post-operative elevation were analyzed, stratified by pre-operative contracture status. Pre-operative shoulder contracture was significantly more frequent in the RA group (59%) than in the CTA group (23%). The deltoid index was significantly smaller in patients with RA compared to those with CTA (738 vs. 946 mm2/m2, P = .0038). The deltoid index showed a strong positive correlation with post-operative active shoulder elevation only in patients with pre-operative contracture (r = 0.61, P = .0020). No significant correlation was observed in patients without contracture. Pre-operative deltoid muscle volume (deltoid index) was an independent predictor of post-operative shoulder elevation after rTSA, particularly in patients with pre-operative contracture. rTSA may compensate for moderate deltoid atrophy in mobile shoulders, whereas the combination of severe deltoid atrophy and contracture may limit post-operative elevation.
Onlay augmentation may enhance healing after arthroscopic rotator cuff repair (aRCR), but the optimal graft remains unclear. This study compared radiographic healing after aRCR performed without augmentation versus with acellular dermal allograft (ADA) or bioinductive collagen implant (BCI) augmentation. This was a retrospective cohort of prospectively collected data. Patients with full-thickness rotator cuff tears who underwent aRCR between May 2021 and April 2024 were included. Tear characteristics and fatty infiltration were assessed radiographically and arthroscopically. Post-operative repair integrity was evaluated on magnetic resonance imaging obtained ≥6 months after surgery. Functional outcomes were recorded pre-operatively and at 3, 6, and 12 months. One hundred twelve patients were included (40 no augmentation, 40 BCI, 32 ADA; mean age 61 ± 9.2 years). BCI showed the highest overall healing rate (78%) versus ADA (53%) and controls (55%) (P = .049). In small-to-medium tears (no augmentation, n = 27; ADA, n = 18; BCI, n = 20), BCI demonstrated a 95% healing rate compared with ADA (72%) and controls (70%) (P = .06). Among patients with Goutallier grade ≤1, BCI was associated with significantly greater healing (85%) than ADA (64%) and controls (57%) (P = .03). On multivariable Poisson regression, BCI augmentation was independently associated with improved healing compared to no augmentation (adjusted relative risk 1.58, 95% confidence interval 1.16-2.16; P < .01). Functional outcomes did not differ among groups at any time point. BCI augmentation was associated with higher healing rates, with the greatest predicted benefit observed in patients with both small-to-medium tears and minimal fatty infiltration. Healing rates were similar between ADA augmentation and no augmentation. Functional outcomes were comparable across groups.
Intramedullary nail (IMNs) for humeral fractures have been associated with iatrogenic rotator cuff damage resulting in poor shoulder function and pain. The purpose of this study was to evaluate nail positioning, clinical outcomes, and complications following IMN using a rotator cuff-sparing approach via the rotator interval. A retrospective review of patients who underwent an IMN for a humeral fracture with a minimum of 12 months follow-up at a single institution was carried out. Patients who underwent a mini-open deltopectoral approach utilizing the rotator interval were eligible. Clinical outcomes assessed included the American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores, impingement, patient satisfaction, and range of motion (ROM). Nail positioning was assessed on radiographic follow up as were complications. There were 22 patients available for radiological follow-up and 20 for clinical follow-up, of which 68.2% were female, the mean age was 67.7 ± 11.7 years, body mass index was 29.7 ± 8.8, and the mean follow-up was 25.9 ± 9.5 months. There were 7 proximal humerus fractures (4 II-part and 3 III-part fractures) and 15 fracture of the proximal shaft. The mean American Shoulder and Elbow Surgeons score was 87.9 ± 12.7, and the mean Single Assessment Numeric Evaluation score was 88.3 ± 12.8. The mean ROM in forward flexion was 149° ± 24°, abduction was 137° ± 27°, and external rotation was 47° ± 16°. There were no significant differences between fracture types for any outcome score or ROM. All nails were buried or flush with the humeral head on lateral x-rays the entry point was graded as central in 77% and anterior in 23% of patients. On AP x-rays, the entry point was graded as central in 87% of cases and lateral in 13%. The mean visual analog scale score was 0.7 ± 1.0, No patients reported persistent shoulder pain, and there were no revision or reoperations required. There was 1 case of delayed union with a broken locking screw and 1 case of adhesive capsulitis. Intramedullary nail of humeral fractures using a third generation nail and a rotator cuff sparing deltopectoral approach results in accurate nail positioning, a low risk of iatrogenic shoulder pain, as well as good ROM and functional outcomes; however, further comparative studies are required.