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Background: Ulnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen., Methods: A retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of 3 fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, HO prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Score, and visual analog scale pain scores., Results: Thirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative vs. long-term postoperative elbow extension (P < .001), flexion (P < .001), and total arc of motion (P < .001). There was a statistically significant improvement in pre- vs. postprocedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2-0.7; P = .002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical comorbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97° and average Mayo Elbow Performance Score of 80 ("good") at long-term follow-up., Conclusions: The combination of operative management, postoperative HO prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs)., Background: Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery., Methods: Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history., Results: We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4)., Conclusion: Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings., Methods: The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups., Results: Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04)., Conclusion: Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: This study is the largest cohort of partial distal biceps brachii tendon ruptures in the literature that was analyzed according to rupture morphology of the long and short tendon heads., Methods: Patients with partial distal biceps tendon ruptures were identified using an institutional enterprise data warehouse query at a single institution. A retrospective chart review was performed to record patient demographics, past medical history, and injury mechanism for each patient. Each patient's magnetic resonance images were reviewed to determine injury patterns, specifically the extent of long head (LH) and short head (SH) tendon involvement, and associated injuries. Rupture morphologies were correlated with mechanism of injury, diabetes status, and smoking history., Results: Seventy-seven patients were included in the study. The average age was 52 years (±11.9, range: 23-90 years); 67% were male, with an average body mass index of 28.3 (±4.3). A smoking history was reported in 31.2% of patients and 5.2% were diabetic. The partial ruptures were caused by a traumatic mechanism in 57.1% of cases, 23.4% were atraumatic, and 19.5% had an unknown mechanism. The most common injury morphology was a partial LH rupture with an intact SH tendon (33.8%). Isolated complete ruptures of the LH represented the least common injury morphology. Injury morphology was significantly related to mechanism (P < .01). Traumatic ruptures had a higher percentage of SH involvement compared with the atraumatic group (77.3% vs. 37.7%, respectively). In contrast, atraumatic ruptures involved the LH tendon in 89% of cases, with only 37.7% of cases involving the SH tendon. Patients with a history of smoking were more likely to have an atraumatic mechanism (P = .01). A history of diabetes was unrelated to mechanism (P = .20)., Conclusion: Partial ruptures of the distal biceps brachii tendon represent a spectrum of patterns with varying involvement of the LH and SH tendons. Injury morphology was significantly related to mechanism (P < .01). LH tendon involvement was seen in 88.9% of atraumatic cases, whereas SH tendon involvement was seen in 77.3% of traumatic cases. A more comprehensive understanding of partial rupture patterns is critical to further understand the risk factors that may preclude to worse clinical outcomes, and aid in deciding which patients would benefit from operative vs. nonoperative management., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The beach chair position is commonly used when performing shoulder arthroplasty. However, this position has been associated with hypotension, potentially leading to cerebral hypoperfusion, which may cause neurologic injury. In addition, shoulder arthroplasty cases are associated with longer operative times, posing a potentially greater risk of cerebral hypoperfusion. We aim to evaluate the risk of cerebral desaturation events (CDEs) during the course of total shoulder arthroplasty., Methods: Twenty-six patients undergoing shoulder arthroplasties were monitored for changes in cerebral perfusion. Seven specific time-points during the procedure were labeled for comparison of events: baseline, beach chair, incision, humeral broaching, glenoid reaming, glenoid component implantation, and humeral component implantation. Cerebral oxygen perfusion was measured using near-infrared spectroscopy. A CDE was described as a decrease of oxygen saturation greater than 20%., Results: Nineteeen of 25 subjects experienced a CDE. 42% of these patients experienced CDEs during semi-beach chair positioning. Patients experienced the largest oxygen saturation drop during semi-beach chair positioning. Transition from baseline to semi-beach chair was the only event to have a statistically significant decrease in cerebral perfusion (8%, P < .05). There was a statistically significant percentage change in mean oxygen saturation in the semi-beach chair interval (10%, P < .01) and the semi-beach chair to incision interval (7%, P < .01)., Conclusions: Most patients experienced an intraoperative CDE, with greatest incidence during semi-beach chair positioning. The largest decline in cerebral oxygen saturation occurred during semi-beach chair positioning. Implant implantation was not associated with decrease in cerebral oximetry., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies have shown no correlation between adhesive capsulitis and hemoglobin A 1c (HbA 1c ). However, HbA 1c is only a measure of short-term blood sugar control. We created a previously nonvalidated variable, cumulative HbA 1c , that uses HbA 1c values over time to estimate the total disease burden a single individual experiences over a period. In this study, we aimed to evaluate whether a correlation exists between cumulative HbA 1c levels in diabetic patients and the prevalence of frozen shoulder. We hypothesized that poor long-term glucose control would be correlated with increased incidence of adhesive capsulitis., Methods: A retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbA 1c values were collected. A total of 24,417 patients met the inclusion criteria. A variable was created establishing the cumulative magnitude of abnormal HbA 1c values over time, termed "cumulative HbA 1c ." Logistic regression analysis was performed to determine whether long-term glucose control was predictive of the development of adhesive capsulitis., Results: Cumulative HbA 1c was positively associated with adhesive capsulitis (7.6 × 10 -5 ) (ie, odds ratio of 1.000076). The effect size of cumulative HbA 1c on adhesive capsulitis was significant; for each unit of time that the HbA 1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis., Discussion: Cumulative HbA 1c was associated with an increased incidence of adhesive capsulitis. This finding suggests that the effects of diabetes that predispose patients to the development of adhesive capsulitis are dose dependent. Patients with worse blood sugar control over a longer period are at an increased risk of the development of adhesive capsulitis., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patients undergoing shoulder surgery in the beach chair position may be at increased risk for serious neurocognitive complications due to cerebral ischemia. We sought to define the incidence, patient risk factors, and clinical sequelae of intraoperative cerebral desaturation events., Methods: Regional cerebral tissue oxygen saturation (rSO2) was monitored intra-operatively using near-infrared spectroscopy (NIRS) on 50 consecutive patients. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was administered to each patient pre- and postoperatively. Intra-operative decreases in rSO2 of 20% or greater were defined as cerebral desaturation events (CDE). The association between intraoperative CDE and postoperative cognitive decline was assessed., Results: The incidence of intraoperative CDE in our series was 18% (9/50). Increased body mass index (BMI) was found to have a statistically significant association with intraoperative CDE (mean BMI 37.32 vs 28.59, P < .0001). There was no statistical significance in pre- vs postoperative RBANS either in composite scores or any of the sub-indices in either group., Conclusion: The degree and duration of cerebral ischemia required to produce neurocognitive dysfunction in this patient population remains undefined; however, cerebral oximetry with NIRS allows prompt identification and treatment of decreased cerebral perfusion decreasing the risk of this event. Increased BMI was found to be a statistically significant patient risk factor for the development of intra-operative CDE. The transient intra-operative CDEs were not associated with postoperative cognitive dysfunction in our patient series. We believe protocols aimed at detecting and reversing CDE minimize the risk of neurocognitive dysfunction and improve patient safety., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Although the biomechanics of the coracoacromial arch and coracoacromial ligament (CAL) morphology are well studied, to our knowledge, the biomechanics of the coracoacromial arch after CAL resection and medial reattachment have not yet been studied. The purpose of this report is to examine the biomechanical consequences of coracoacromial arch alteration and subsequent reconstruction in cadaveric specimens. Anterosuperior humeral head translation was measured after the application of an anterosuperior 150-N load under 5 sequential scenarios: (1) intact CAL, (2) subperiosteal CAL release, (3) standard acromioplasty, (4) CAL reconstruction, and (5) modified Neer acromioplasty. A significant decrease in anterosuperior migration was found after CAL reconstruction compared with both anterior acromioplasty (P = .038) and modified Neer acromioplasty (P = .01). Thus, in patients with massive rotator cuff tears, reconstruction of the CAL may provide the necessary stabilizing force to prevent excessive anterosuperior translation and possible humeral head escape from the coracoacromial arch.

Background: While fracture and nonunion of the olecranon have been reported in patients undergoing total elbow arthroplasty, little information exists about the management and outcome of these cases., Methods: Twenty-four patients (twenty-five elbows) were studied; fifteen (sixteen elbows) with rheumatoid arthritis and nine with post-traumatic elbow disorders. Twenty-three of the twenty-five elbows presented with an olecranon fracture or nonunion prior to the reported arthroplasty. During arthroplasty the olecranon fragment was initially treated by tension band in sixteen elbows, excision in four, suture fixation in two and three with stable fibrous union were left alone., Results: At an average follow-up of 66 months (range, 18 to 242), there were twelve excellent, nine good, three fair and one poor results. The mean pre-operative Mayo Elbow Performance Score improved from 42 (range, 20 to 62) points pre-operatively to 86 (range, 50 to 100) points post-operatively (p < 0.001). Of the eighteen patients undergoing an attempt at union, nine (50%) obtained osseous union, eight (45%) developed a stable fibrous union and one patient underwent subsequent excision of the fragment due a superficial infection (5%). Fifteen of twenty-one could extend the hand above the head against gravity., Conclusion: A functional arc of motion and satisfactory clinical outcome can be achieved with osseous or a stable fibrous nonunion.

One hundred consecutive stiff shoulders in 93 patients resistant to conservative therapy were treated with surgery and intermittent regional anesthesia via indwelling interscalene catheter. Each patient underwent manipulation and one of several operative treatments to release any additional contracture. The indwelling interscalene catheter remained in place and functioned well for an average of 3 days in 87 shoulders. At an average follow-up of 3.0 years, overall clinical results according to Neer's criteria were excellent in 39 shoulders (39%), satisfactory in 28 (28%), and unsatisfactory in 33 (33%). Patients reported no or mild pain in 83 (83%) of the shoulders in the study. At final follow-up, average gains in motion were 44 degrees of elevation (115 degrees to 159 degrees), 31 degrees of external rotation (22 degrees to 53 degrees), and 5 spine segments of internal rotation (L4 to T11). At final follow-up, 95% of the elevation and 79% of the external rotation achieved intraoperatively were maintained. The best results were obtained in those shoulders with idiopathic stiffness (88% excellent or satisfactory results); the worst results were in the postsurgical shoulders (47% excellent or satisfactory results). There were no catheter-related complications. The use of an indwelling interscalene catheter for postoperative pain control is a safe technique that facilitates early physical therapy in a patient population with a high risk of developing recurrent stiffness.