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Although it is commonly believed that the innovation of new medicines is of paramount importance for improving the health and quality of life of patients, there is also a keen recognition regarding upward-spiraling costs of innovation, drug discovery, and drug development against a backdrop of dwindling successes in research and development (R&D) efforts. We propose a new model of valuation of pharmacotherapies that attempts to secure an adequate return on investment in innovation by ensuring optimal pricing and reimbursement.Clinical Pharmacology & Therapeutics (2008); 84, 2, 263–266 doi:10.1038/clpt.2008.117 [ABSTRACT FROM AUTHOR]

Background: Utilization in outpatient total shoulder arthroplasties (TSAs) has increased significantly in recent years. It remains largely unknown whether utilization of outpatient TSA differs across gender and racial groups. This study aimed to quantify racial and gender disparities both nationally and by geographic regions., Methods: 168,504 TSAs were identified using Medicare fee-for-service inpatient and outpatient claims data and beneficiary enrollment data from 2020 to 2022Q4. The percentage of outpatient cases, defined as cases discharged on the same day of surgery, was evaluated by racial and gender groups and by different census divisions. A multivariate logistics regression model controlling for patient sociodemographic information (White vs. non-White race, age, gender, and dual eligibility for both Medicare and Medicaid), hierarchical condition category (HCC) score, hospital characteristics, year fixed effects, and patient residency state fixed effects was performed., Results: The TSA volume per 1000 beneficiaries was 2.3 for the White population compared with 0.8, 0.6, and 0.3 for the Black, Hispanic, and Asian population, respectively. A higher percentage of outpatient TSAs were in White patients (25.6%) compared with Black patients (20.4%) (P < .001). The Black TSA patients were also younger, more likely to be female, more likely to be dually eligible for Medicaid, and had higher HCC risk scores. After controlling for patient sociodemographic characteristics and hospital characteristics, the odds of receiving outpatient TSAs were 30% less for Black than the White group (odds ratio 0.70). Variations were observed across different census divisions, with South Atlantic (0.67, P < .01), East North Central (0.56, P < .001), and Middle Atlantic (0.36, P < .01) being the 4 regions observed with significant racial disparities. Statistically significant gender disparities were also found nationally and across regions, with an overall odds ratio of 0.75 (P < .001)., Discussion: Statistically significant racial and gender disparities were found nationally in outpatient TSAs, with Black patients having 30% (P < .001) fewer odds of receiving outpatient TSAs than White patients, and female patients with 25% (P < .001) fewer odds than male patients. Racial and gender disparities continue to be an issue for shoulder arthroplasties after the adoption of outpatient TSAs., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Postoperative dislocation is a known complication following reverse shoulder arthroplasty (RSA), but treatment patterns and outcomes remain unclear. The purpose of this study was to identify treatment patterns, rate of successful closed reductions, and factors associated with unsuccessful closed reductions for dislocations after RSA in a large multicenter patient cohort., Methods: A multicenter retrospective review was performed for patients receiving primary or revision RSA from June 2013 to May 2019 across fifteen institutions in the United States. Patients that sustained a postoperative shoulder dislocation (defined as complete loss of articulation between the humeral component and glenosphere confirmed on imaging) with a minimum of 3-month follow-up were included. The time from surgery to dislocation, nature of the dislocation, complications associated with the dislocation, initial treatment, success of closed reduction, recurrent dislocations, and subsequent treatments including revision procedures, were recorded. Univariate analysis was performed to identify patient factors associated with failure of an initial closed reduction attempt., Results: A cumulative postoperative dislocation incidence of 2.1% (n=138) was observed out of 6,621 patients undergoing RSA. The median time to dislocation was 7 weeks (interquartile range = 33 weeks), with 61.6% (n=85) occurring within the first 90 days after surgery. Initial treatment consisted of closed reduction (n=87, 63.0%), open reduction (n=1, 0.7%), revision arthroplasty (n=43, 31.2%), or benign neglect (n=7, 5.1%). Those treated without an initial closed reduction had higher incidence of associated complications (45.1% vs. 14.9%). Among patients initially treated with a closed reduction, 27 (31.0%) were successful (required no further interventions), 15 (17.2%) subsequently required a revision procedure, and 43 (49.4%) sustained an additional dislocation. The only patient or surgical factor associated with an unsuccessful closed reduction was increased BMI (31.8±6 vs. 28.9±5.2, P=0.02). Of the 43 patients that sustained an additional dislocation, 10 received another closed reduction and 30 received revision surgery. Among the 10 patients that received a second closed reduction, 5 remained stable (50.0%). Overall, 92 patients (66.7%) required a revision arthroplasty procedure during the study period, whereas 22 (22.5%) required multiple revision procedures. Ultimately, 18 patients (13.0%) remained unstable (benign neglect) at final follow-up., Conclusion: In this large multicenter series of postoperative dislocations following RSA, a closed reduction was initially attempted in the majority of patients, but only about one-third were successful and required no further intervention. Unsuccessful closed reductions were associated with higher patient BMI. Revision surgery for dislocations was complicated by a high rate of recurrent dislocations and re-revision surgery., (Copyright © 2024. Published by Elsevier Inc.)

Damage control laparotomy (DCL) has a high risk of SSI and as an attempt to mitigate this, surgeons often leave the skin open to heal by secondary intention. A recent retrospective study showed that DCL wounds could be closed with the addition of wicks or incisional wound vacs with acceptable rates of wound infection. The aim of this prospective trial was to corroborate these results. This is a prospective multicenter observational trial performed by 7 institutions from July 2020 to April 2022. Adult patients who underwent DCL and fascia/skin closure with the addition of wicks or an incisional wound vac were included. Patients who died within seven days of DCL were excluded. Demographics, mechanism of initial presentation, wound classification, antibiotics given, surgical site infections, procedures performed, and mortality data was collected. Fisher's Exact test was used for categorical data and Wilcoxon Rank Sum test for continuous data. Mean days to closure was assessed using Student's t-test for independent groups. P-values <0.05 were considered indicative of statistical significance. Over the 21-month period, a total of 119 patients analyzed. Most patients were male (n = 66, 63 %), and the average age was 51 years. The average number of days the abdomen was kept open was 2.6. A majority of the DCLs were performed on acute care patients (n = 76, 63.8 %) and 92 patients (77.3 %) had a wound classification of contaminated or dirty. Most of the patients' skin was closed with wicks in place (68.9 %). There was a 9.8 % infection rate in patient's skin closed with wicks versus 16.2 % closed with an incisional wound vac (p = 0.361). Although the wick group had a higher proportion of class III and IV wound types, patients primarily treated with wicks had a lower risk of wound infection compared to those treated with incisional wound VACs; however, this difference was not statistically significant., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The COVID-19 pandemic was managed in part by the rapid development of vaccines, diagnostics, and therapeutics including antiviral agents and advances in emergency airway and ventilatory management. The impact of these therapeutic advances on clinically pertinent metrics of emergency care have not been well-studied., Methods: We abstracted data from emergency department (ED) visits made to 21 US health systems during the first two years of the pandemic, from February 1, 2020 to January 31, 2022. These health systems were participants in the NIH-supported COVID EHR Cohort, in which the University of Wisconsin served as the coordinating site. Limited patient-level data files were submitted monthly. Data elements included demographic and clinical variables, as well as standard measures of ED outcomes including 72-h returns, 72-h returns leading to readmission, and in-hospital mortality. Multivariable models were fitted to identify correlates of each of the dependent variables. A test for trend was used to detect changes in outcomes over time., Results: During the two-year period, 150,357 individuals aged 18 years or older visited the ED. The median age was 45.4 years (IQR 27), 58.1 % were female, 49 % were White, 18.3 % Hispanic/Latino, and 45 % were publicly insured or uninsured. The prevalence of 72-h ED returns, readmissions, and in-hospital mortality significantly declined across the two-year period. SARS-CoV-2 vaccination was associated with reduced ED returns and mortality. Therapeutic agents were associated with increased mortality risk but were likely confounded by unmeasured covariates., Conclusions: Operational and clinical outcomes of ED-based treatment of individuals with COVID-19 improved in the first two years of the pandemic. This improvement is likely multifactorial and includes the development and deployment of SARS-CoV-2-specific vaccines, therapeutic agents, and improved healthcare delivery in the ED and elsewhere addressing management of airway and ventilatory status, as well as increased innate immunity in the general population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024. Published by Elsevier Inc.)

Background: Revision shoulder arthroplasty continues to add an increasing burden on patients and the healthcare system. This study aimed to delineate long-term shoulder arthroplasty revision incidence, quantify associated Medicare spending, and identify relevant predictors of both revision and spending., Methods: The complete 2016-2022(Q3) Medicare fee-for-service inpatient and outpatient claims data was analyzed. Patients receiving a primary total shoulder arthroplasty for osteoarthritis, rotator cuff pathology, or inflammatory arthropathy were included and subsequent ipsilateral revision surgeries were identified. The time to revision was modeled using the Prentice, Williams, and Peterson Gap Time Model. Medicare spending within 90 days post-discharge was modeled using a generalized linear model. The analysis was subdivided by index procedure type: anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA)., Results: A total of 82,949 primary TSAs and 172,524 RSAs were identified. Compared to index TSA cases, index RSA cases had a lower first revision rate in an observation window of nearly 7 years (1.9% vs. 3.5%, p<0.001), but a higher rate of second (11.4% vs. 4.9%, p<0.001) as well as third revision (13.8% vs. 13.8%, p=0.449). TSA spending was significantly lower than RSA spending for the index procedure ($21,531 vs. $23,267, p<0.001), first ($23,096 vs. $26,414, p<0.001), and second ($25,060 vs. $29,983, p<0.001) revision. There was no statistically significant difference in third revision between TSA and RSA groups ($31,313 vs. $30,829, p=0.860). Age, sex, race, and rheumatoid arthritis were among the top predictors of revisions. Top predictors of Medicare spending included having a non-osteoarthritis surgical indication, a hospital stay of three or more days, a discharge to a setting other than home, malnutrition, dementia, stroke, major kidney diseases, and being operated on in a teaching hospital., Conclusion: Compared with TSA, RSA was associated with a lower first revision rate, but a higher subsequent revision rate. An index RSA procedure was also associated with higher initial Medicare spending as well as subsequent revision surgery spending compared with an index TSA procedure. Demographics and comorbid medical conditions were among the top predictors of revisions, while procedure-related factors predicted Medicare spending., (Copyright © 2024. Published by Elsevier Inc.)

Background: This study aimed to assess the medical costs, and the combined costs of fatal firearm injury and fatal falls during a 5 year period. While fatal firearm injury represents a significant public health concern, the healthcare community is faced with the significant challenge of fatal falls, particularly in light of the elderly population growth., Methods: Data were exported from the Web-based Injury Statistics Query and Reporting System database for fatal firearm and falls in patients aged between 15-85 years-old. The primary outcome was medical cost and the secondary outcome was combined costs (combination of medical costs and value of statistical life)., Results: The medical cost of fatal falls was significantly higher in 2015-2020 in all age groups. The combined cost was significantly higher in fatal firearm injury overall. We found the combined cost was higher in fatal falls after 2019 for patients in the 45-85+ age range. During 2015-2019, the percentage of fatal falls had a significant increase in all age ranges, with a rise in the slope in 2019 for patients over 65 years. The annual percent change (APC) for the proportion of fatal falls increased from 2015 to 2020, there was a significant increase in the slope after 2019 (2.81% APC before 2019 vs 6.95% after 2019)., Conclusion: Geriatric fatal falls have significantly higher medical costs compared with fatal firearm injury. The combined cost for fatal falls exceeded fatal firearm injury after 2019 which highlights the increasing socioeconomic burden of an aging population., Level of Evidence: Level III retrospective study., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Numerous applications and strategies have been utilized to help assess the trends and patterns of readmissions after orthopaedic surgery in an attempt to extrapolate possible risk factors and causative agents. The aim of this work is to systematically summarize the available literature on the extent to which natural language processing, machine learning, and artificial intelligence (AI) can help improve the predictability of hospital readmissions after orthopaedic and spine surgeries., Methods: This is a systematic review and meta-analysis. PubMed, Embase and Google Scholar were searched, up until August 30, 2023, for studies that explore the use of AI, natural language processing, and machine learning tools for the prediction of readmission rates after orthopedic procedures. Data regarding surgery type, patient population, readmission outcomes, advanced models utilized, comparison methods, predictor sets, the inclusion of perioperative predictors, validation method, size of training and testing sample, accuracy, and receiver operating characteristics (C-statistic), among other factors, were extracted and assessed., Results: A total of 26 studies were included in our final dataset. The overall summary C-statistic showed a mean of 0.71 across all models, indicating a reasonable level of predictiveness. A total of 15 articles (57%) were attributed to the spine, making it the most commonly explored orthopaedic field in our study. When comparing accuracy of prediction models between different fields, models predicting readmissions after hip/knee arthroplasty procedures had a higher prediction accuracy (mean C-statistic = 0.79) than spine (mean C-statistic = 0.7) and shoulder (mean C-statistic = 0.67). In addition, models that used single institution data, and those that included intraoperative and/or postoperative outcomes, had a higher mean C-statistic than those utilizing other data sources, and that include only preoperative predictors. According to the Prediction model Risk of Bias Assessment Tool, the majority of the articles in our study had a high risk of bias., Conclusion: AI tools perform reasonably well in predicting readmissions after orthopaedic procedures. Future work should focus on standardizing study methodologies and designs, and improving the data analysis process, in an attempt to produce more reliable and tangible results., Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B118)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty., Methods: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes., Results: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001)., Discussion: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued., Level of Evidence: Level III, therapeutic retrospective cohort study., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Clinically significant outcome (CSO) benchmarks have been previously established for shoulder arthroplasty by assimilating preoperative diagnoses and arthroplasty types. The purpose of this study was to establish unique CSO thresholds and compare the time-to-achievement of these for reverse shoulder arthroplasty (RSA) for osteoarthritis (GHOA), RSA for rotator cuff arthropathy (RCA), and total shoulder arthroplasty (TSA) for GHOA., Materials and Methods: Consecutive patients who underwent elective RSA for GHOA, TSA for GHOA, or RSA for RCA between February 2015 and May 2020, with 2-year minimum follow-up, were retrospectively identified from a prospectively maintained single surgeon registry. The American Shoulder and Elbow Surgeons (ASES) score was administered preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year timepoints. Satisfaction and subjective overall improvement anchor questionnaires were administered at the time of final follow-up. Distribution-based methods were used to calculate the Minimal Clinically Important Difference (MCID), and anchor-based methods were used to calculate the Substantial Clinical Benefit (SCB) and the Patient Acceptable Symptom State (PASS) for each patient group. Median time to achievement, individual incidence of achievement at each time point, and cumulative incidence of achievement calculated using Kaplan-Meier survival curve analysis with interval censoring were compared between groups for each CSO. Cox-regression analyses were also performed to determine which patient factors were significantly associated with early or delayed achievement of CSOs., Results: There were 471 patients eligible for study analysis: 276 RSA for GHOA, 107 TSA for GHOA, and 88 RSA for RCA. The calculated MCID, SCB, and PASS scores differed for each group. There were no significant differences in median time to achievement of any CSO between groups. Log-rank testing revealed that cumulative achievements significantly differed between groups for MCID (P = .014) but not for SCB (P = .053) or PASS (P = .620). On cox regression analysis, TSA patients had earlier achievement of SCB, whereas TSA and RSA for GHOA patients had earlier achievement of MCID. At 2-years, a significantly higher percentage of RSA for GHOA patients achieved MCID and SCB compared to RSA for RCA (MCID:100%, 95.5%, P = .003, SCB:94.6%, 86.4%, P = .036)., Conclusion: Calculated CSO thresholds differ according to preoperative diagnosis and shoulder arthroplasty type. Patients undergoing TSA and RSA for GHOA achieve CSOs earlier than RSA for RCA patients, and a significantly higher percentage of RSA for GHOA patients achieve CSOs by 2 years compared to RSA for RCA patients., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: As reverse shoulder arthroplasty (RSA) continues to grow in popularity for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff, it becomes increasingly important to identify factors that influence postoperative outcome. Although recent studies have demonstrated excellent postoperative range of motion and patient-reported outcome scores following RSA for GHOA, there continues to be surgeon hesitation to adopt RSA as a viable treatment in the younger patient population due to greater functional demands. In this study, we sought to determine the effect of age on clinical outcomes following RSA for GHOA through a comparison of patients over and under the age of 70., Methods: A retrospective review of prospectively collected data from an institutional registry was performed. Propensity score matching was utilized to match patients under the age of 70 (U-70) to those over 70 (O-70) in a 1:1 ratio based on sex, body mass index (BMI), preoperative ASES score, preoperative active forward elevation (FE), Walch classification, and American Society of Anesthesiologists comorbidity score. Clinical outcomes obtained preoperatively and at a minimum of 2 years postoperatively consisted of Visual Analog Scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE) score, and American Shoulder and Elbow Surgeons (ASES) score, as well as active (FE), internal rotation, and external rotation. Descriptive statistics and univariate analysis were performed to compare cohorts., Results: After matching, each cohort consisted of 66 patients with similar mean follow-up periods (U-70, 28.1 ± 7.5 months vs. O-70, 27.4 ± 7.5 months; P = .887). Mean age of the U-70 cohort was 66.2 ± 3.3 while the O-70 cohort had a mean age of 75.3 ± 3.8. Both groups demonstrated significant improvement in VAS, SANE, and ASES scores, as well as active range of motion in all planes. The only significant difference between cohorts was greater postoperative FE in younger patients (143 ± 16° vs. 136 ± 15°; P = .017), though the baseline-to-postoperative improvement in FE was similar between cohorts (50 ± 29° vs. 43 ± 29°, P = .174)., Conclusion: RSA is a successful surgical treatment for GHOA regardless of age. Aside from greater postoperative FE in younger patients, there were no other differences in clinical outcomes between younger and older patients in this retrospective analysis, which compared patients who were matched by sex, BMI, and Walch classification, among other factors. Based on our results, 70 years of age should not be used as a threshold in preoperative counseling when determining whether a patient with GHOA with an intact rotator cuff is indicated for reverse shoulder arthroplasty., (Copyright © 2024. Published by Elsevier Inc.)

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection., Competing Interests: Competing interests: TC reports: Innovital—funding paid to my institution related to research performed; Cytovale—direct payments to me for research-related medical monitoring. SM reports: UpToDate—Author Royalty; AHRQ grant funding, but not related to this topic. LK reports: Eastern Association for the Surgery of Trauma Vice Chair Guidelines Committee; American Association for the Surgery of Trauma Palliative Care Committee, American Association for the Surgery of Trauma Critical Care Committee, American College of Surgeons Geriatric Surgery Verification Standards and Verification Committee, Journal of Surgical Research Editorial Board Member. DMS reports: grant funding from PCORI, DoD, NIH, NHTSA and consultant fees—CSL Behring., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: RG reports honoraria for lectures/presentations: Morristown Memorial Hospital—keynote speaker honorarium, payments made to the author; Leadership in Board/Society: Chair, Scientific Studies Committee, Surgical Infection Society—unpaid; Payment for Expert Testimony: Billing, Cochran, Lyles, Mauro & Ramsey PA; Rafi Law Firm; Foy & Associates PC. SM reports UpToDate—author royalty; AHRQ grant funding, but not related to this topic. TR reports receiving an honorarium from Stanford Hospital/Santa Clara Valley Medical Center for speaking at their annual trauma; support from the author's home institution (UC Davis) for attendance at meetings (WTA in 2022, 2023). DMS reports grant funding from PCORI, DoD, NIH, and NHTSA and consultant fees from CSL Behring.

Background: With the increased utilization of Total Shoulder Arthroplasty (TSA) in the outpatient setting, understanding the risk factors associated with complications and hospital readmissions becomes a more significant consideration. Prior developed assessment metrics in the literature either consisted of hard-to-implement tools or relied on postoperative data to guide decision-making. This study aimed to develop a preoperative risk assessment tool to help predict the risk of hospital readmission and other postoperative adverse outcomes., Methods: We retrospectively evaluated the 2019-2022(Q2) Medicare fee-for-service inpatient and outpatient claims data to identify primary anatomic or reserve TSAs and to predict postoperative adverse outcomes within 90 days postdischarge, including all-cause hospital readmissions, postoperative complications, emergency room visits, and mortality. We screened 108 candidate predictors, including demographics, social determinants of health, TSA indications, prior 12-month hospital, and skilled nursing home admissions, comorbidities measured by hierarchical conditional categories, and prior orthopedic device-related complications. We used two approaches to reduce the number of predictors based on 80% of the data: 1) the Least Absolute Shrinkage and Selection Operator logistic regression and 2) the machine-learning-based cross-validation approach, with the resulting predictor sets being assessed in the remaining 20% of the data. A scoring system was created based on the final regression models' coefficients, and score cutoff points were determined for low, medium, and high-risk patients., Results: A total of 208,634 TSA cases were included. There was a 6.8% hospital readmission rate with 11.2% of cases having at least one postoperative adverse outcome. Fifteen covariates were identified for predicting hospital readmission with the area under the curve of 0.70, and 16 were selected to predict any adverse postoperative outcome (area under the curve = 0.75). The Least Absolute Shrinkage and Selection Operator and machine learning approaches had similar performance. Advanced age and a history of fracture due to orthopedic devices are among the top predictors of hospital readmissions and other adverse outcomes. The score range for hospital readmission and an adverse postoperative outcome was 0 to 48 and 0 to 79, respectively. The cutoff points for the low, medium, and high-risk categories are 0-9, 10-14, ≥15 for hospital readmissions, and 0-11, 12-16, ≥17 for the composite outcome., Conclusion: Based on Medicare fee-for-service claims data, this study presents a preoperative risk stratification tool to assess hospital readmission or adverse surgical outcomes following TSA. Further investigation is warranted to validate these tools in a variety of diverse demographic settings and improve their predictive performance., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: As the indications for reverse total shoulder arthroplasty (RSA) continue to evolve, it has been more commonly utilized for the treatment of glenohumeral osteoarthritis with an intact rotator cuff (GHOA). Given the increased use of RSA for GHOA, it is important to identify factors influential of clinical outcomes. In this study, we sought to identify variables predictive of clinical outcomes following RSA for GHOA., Methods: Patients undergoing primary RSA for GHOA between 2015 and 2020 were retrospectively identified through a prospectively maintained, single surgeon registry. Eligible patients had complete patient-reported outcome measures and range of motion measurements with a minimum 2-year follow-up. Univariate analysis was utilized to compare characteristics and outcome measures of patients with poor and excellent outcomes, which was defined as postoperative American Shoulder and Elbow Surgeons (ASES) scores in the bottom and top quartiles, respectively. Multivariate linear regression was performed to determine factors independently predictive of postoperative ASES score., Results: A total of 230 patients were included with a mean follow-up of 33.4 months (SD 13.2). The mean age of the study population was 71.9 (SD 6.1). Two hundred twenty-four patients (97.4%) surpassed the minimal clinically important difference and 209 patients (90.1%) achieved substantial clinical benefit for ASES score. Preoperative factors differing between the poor and excellent outcome groups were sex (male: poor 37.9%, excellent 58.6%; P = .041), opioid use (poor 24.1%, excellent 5.2%; P = .009), ASES score (poor 32.9, excellent 41.0; P = .011), and forward elevation (poor 92°, excellent 101°; P = .030). Linear regression demonstrated that Walch B3 glenoids (β 7.08; P = .010) and higher preoperative ASES scores (β 0.14; P = .025) were predictors of higher postoperative ASES score, while postoperative complications (β -18.66; P < .001) and preoperative opioid use (β -11.88; P < .001) were predictive of lower postoperative ASES scores., Conclusion: Over 90% of patients who underwent RSA for GHOA with an intact rotator cuff experienced substantial clinical benefit. An unsurprising handful of factors were associated with postoperative clinical outcomes; higher preoperative ASES scores were slightly associated with higher postoperative ASES, whereas preoperative opioid use and postoperative complications were associated with lower postoperative ASES. Additionally, Walch glenoid type B3 was associated with higher postoperative ASES, indicating that patients with posterior glenoid defects are not predisposed to poor clinical outcomes following RSA. These results serve as a resource to improve preoperative patient counseling and manage postoperative expectations., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: As the utilization and success of reverse total shoulder arthroplasty (RTSA) have continued to grow, so have its surgical indications. Despite the adoption of RTSA for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff and irreparable massive rotator cuff tears (MCTs) without arthritis, the literature remains sparse regarding the differential outcomes after RTSA among these varying indications. Thus, the purpose of this study was to examine the postoperative clinical outcomes of RTSA based on indication., Methods: A retrospective review of 2 large institutional databases was performed to identify all patients who underwent RTSA between 2015 and 2019 with minimum 2-year follow-up. Patients were stratified by indication into 3 cohorts: GHOA, rotator cuff tear arthropathy (CTA), and MCT. Baseline demographic characteristics were collected to determine differences between the 3 cohorts. Clinical outcomes were measured preoperatively and postoperatively, including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation score, and visual analog scale pain score. Multivariate linear regression was performed to determine the factors independently predictive of the postoperative ASES score., Results: A total of 625 patients (383 with GHOA, 164 with CTA, and 78 with MCTs) with a mean follow-up period of 33.4 months were included in the analysis. Patients with GHOA had superior ASES scores (85.6 ± 15.7 vs. 76.6 ± 20.8 in CTA cohort [P < .001] and 75.9 ± 19.9 in MCT cohort [P < .001]), Single Assessment Numeric Evaluation scores (86 ± 20.9 vs. 76.7 ± 24.1 in CTA cohort [P < .001] and 74.2 ± 25.3 in MCT cohort [P < .001]), and visual analog scale pain scores (median [interquartile range], 0.0 [0.0-1.0] vs. 0.0 [0.0-2.0] in CTA cohort [P < .001] and 0.0 [0.0-2.0] in MCT cohort [P < .001]) postoperatively. Postoperative active forward elevation (P < .001) and improvement in active external rotation (P < .001) were greatest in the GHOA cohort compared with other indications. Multivariate linear regression demonstrated that the factors independently associated with the postoperative ASES score included a diagnosis of GHOA (β coefficient, 7.557 [P < .001]), preoperative ASES score (β coefficient, 0.114 [P = .009]), female sex (β coefficient, -4.476 [P = .002]), history of surgery (β coefficient, -3.957 [P = .018]), and postoperative complication (β coefficient, -13.550 [P < .001])., Conclusion: RTSA for the treatment of GHOA generally has superior patient-reported and functional outcomes when compared with CTA and MCTs without arthritis. Long-term follow-up is needed to identify the lasting implications of such outcome differences., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN., Methods: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed., Results: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(β -24.9, 95%CI -39.0 to -10.7,p < 0.001)., Conclusion: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible., Level of Evidence: IV., Competing Interests: Conflict of Interest: All JTACS disclosure forms have been supplied and are provided as supplemental digital content (http://links.lww.com/TA/D807)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Insertion sequence (IS) elements are mobile genetic elements in bacterial genomes that support adaptation. We developed a database of IS elements coupled to a computational pipeline that identifies IS element insertions in the microbiota. We discovered that diverse IS elements insert into the genomes of intestinal bacteria regardless of human host lifestyle. These insertions target bacterial accessory genes that aid in their adaptation to unique environmental conditions. Using IS expansion in Bacteroides, we show that IS activity leads to the insertion of "hot spots" in accessory genes. We show that IS insertions are stable and can be transferred between humans. Extreme environmental perturbations force IS elements to fall out of the microbiota, and many fail to rebound following homeostasis. Our work shows that IS elements drive bacterial genome diversification within the microbiota and establishes a framework for understanding how strain-level variation within the microbiota impacts human health., Competing Interests: Declaration of interests B.A.D. is a co-founder and shareholder of Ancilia Biosciences., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Displaced olecranon fractures constitute a challenging problem for elbow surgeons. The purpose of this study is to evaluate the role of suture anchor fixation for treating patients with displaced olecranon fractures., Methods: A retrospective review was performed for all consecutive patients with displaced olecranon fractures treated with suture anchor fixation with at least 2 years of clinical follow-up. Surgical repair was performed acutely in all cases with nonmetallic suture anchors in a double-row configuration utilizing suture augmentation via the triceps tendon. Osseous union and perioperative complications were uniformly assessed., Results: Suture anchor fixation was performed on 17 patients with displaced olecranon fractures. Functional outcome scores were collected from 12 patients (70.6%). The mean age at the time of surgery was 65.6 years, and the mean follow-up was 5.6 years. Sixteen of 17 patients (94%) achieved osseous union in an acceptable position. No hardware-related complications or fixation failure occurred. Mean postoperative shortened disabilities of the arm, shoulder, and hand (QuickDASH) score was 3.8±6.9, and mean Oxford Elbow Score was 47.5±1.0, with nine patients (75%) achieving a perfect score., Conclusions: Suture anchor fixation of displaced olecranon fractures resulted in excellent midterm functional outcomes. Additionally, this technique resulted in high rates of osseous union without any hardware-related complications or fixation failures. Level of evidence: IV.

Background: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants., Methods: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA., Results: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001)., Conclusion: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status., Methods: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis., Results: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort., Conclusion: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Severe glenohumeral osteoarthritis (GHOA) with posterior glenoid erosion remains challenging to address for shoulder surgeons. Whereas anatomic total shoulder arthroplasty (TSA) has historically been the treatment of choice, reverse shoulder arthroplasty (RSA) offers an alternative option. Limited evidence exists directly comparing these 2 treatments in a similar patient population. The purpose of this study was to compare the clinical outcomes of patients with GHOA and Walch type B2 and B3 glenoid morphologies treated with TSA vs. RSA., Methods: We performed a multicenter retrospective cohort study of patients with GHOA who were treated with primary shoulder arthroplasty and had a minimum follow-up period of 2 years. Preoperative computed tomography was used to determine type B2 and B3 glenoid morphology as described by the modified Walch classification. Three-dimensional perioperative planning software was used to characterize glenoid retroversion and humeral subluxation. Patients were categorized based on type of arthroplasty (TSA or RSA) and were matched 1:1 by sex, Walch classification, and age. Patient-reported outcome measures, active range of motion, presence and severity of glenoid loosening, and complications were compared. The percentage of patients who reached previously established clinically significant thresholds of the minimal clinically important difference and substantial clinical benefit for the American Shoulder and Elbow Surgeons score was also comparatively assessed., Results: In total, 202 patients (101 per group) with GHOA and type B2 or B3 glenoids were included in the 1:1 matched analysis. The mean length of follow-up (± standard deviation) was 39 ± 18.7 months. The cohorts were well matched, with no differences in sex, age, American Society of Anesthesiologists score, body mass index, preoperative glenoid morphology (Walch classification), glenoid retroversion, or posterior subluxation (P > .05). RSA was associated with a lower postoperative visual analog scale pain score (0.5 in RSA group vs. 1.2 in TSA group, P = .036); however, no other no other significant differences in patient-reported significant differences in patient-reported outcome measures were found. Most patients in both groups (95.0% in TSA group vs. 98.0% in RSA group, P = .436) reached the minimal clinically important difference, and 82% of TSA patients and 90% of RSA patients reached the substantial clinical benefit value (P = .292). No significant differences in the overall complication rate (P = .781) and active range of motion were found, with the exception of internal rotation (scored on a numeric scale) being worse in the RSA group (2.7 preoperatively and 5.2 postoperatively in RSA group vs. 3.9 and 6.5, respectively, in TSA group; P < .001). Baseplate loosening occurred in 2 RSA cases, and 29 TSA cases had glenoid radiolucencies (P < .001), with 3 grossly loose glenoid components., Conclusion: Primary RSA results in short-term outcomes largely comparable to those of TSA in patients with Walch type B2 or B3 glenoid morphology. Both TSA and RSA provide substantial clinical benefit to patients with significant posterior glenoid wear., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur., Methods: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy)., Results: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA., Conclusion: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Prior research has focused on host factors as mediators of exaggerated sepsis-associated morbidity and mortality in older adults. This focus on the host, however, has failed to identify therapies that improve sepsis outcomes in the elderly. We hypothesized that the increased susceptibility of the aging population to sepsis is not only a function of the host but also reflects longevity-associated changes in the virulence of gut pathobionts. We utilized two complementary models of gut microbiota-induced experimental sepsis to establish the aged gut microbiome as a key pathophysiologic driver of heightened disease severity. Further murine and human investigations into these polymicrobial bacterial communities demonstrated that age was associated with only subtle shifts in ecological composition but also an overabundance of genomic virulence factors that have functional consequence on host immune evasion. IMPORTANCE Older adults suffer more frequent and worse outcomes from sepsis, a critical illness secondary to infection. The reasons underlying this unique susceptibility are incompletely understood. Prior work in this area has focused on how the immune response changes with age. The current study, however, focuses instead on alterations in the community of bacteria that humans live with within their gut (i.e., the gut microbiome). The central concept of this paper is that the bacteria in our gut evolve along with the host and "age," making them more efficient at causing sepsis., Competing Interests: The authors declare no conflict of interest.

Insertion sequences (IS) are simple transposons implicated in the genome evolution of diverse pathogenic bacterial species. Enterococci have emerged as important human intestinal pathogens with newly adapted virulence potential and antibiotic resistance. These genetic features arose in tandem with large-scale genome evolution mediated by mobile elements. Pathoadaptation in enterococci is thought to be mediated in part by the IS element IS256 through gene inactivation and recombination events. However, the regulation of IS256 and the mechanisms controlling its activation are not well understood. Here, we adapt an IS256-specfic deep sequencing method to describe how chronic lytic phage infection drives widespread diversification of IS256 in E. faecalis and how antibiotic exposure is associated with IS256 diversification in E. faecium during a clinical human infection. We show through comparative genomics that IS256 is primarily found in hospital-adapted enterococcal isolates. Analyses of IS256 transposase gene levels reveal that IS256 mobility is regulated at the transcriptional level by multiple mechanisms in E. faecalis, indicating tight control of IS256 activation in the absence of selective pressure. Our findings reveal that stressors such as phages and antibiotic exposure drives rapid genome-scale transposition in the enterococci. IS256 diversification can therefore explain how selective pressures mediate evolution of the enterococcal genome, ultimately leading to the emergence of dominant nosocomial lineages that threaten human health., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kirsch et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology., Methods: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores., Results: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006)., Conclusion: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption., Methods: We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables., Results: Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035)., Conclusion: LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty., Methods: We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores., Results: Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77)., Conclusions: Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair., Methods: This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance., Results: There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery., Conclusion: The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Entomopathogenic fungi allow chemical-free and environmentally safe vector management. Beauveria bassiana (Balsamo-Crivelli) Vuillemin is a promising biological control agent and an important component of integrated vector management. We investigated the mortality of Aedes albopictus (Skuse) larvae exposed to five concentrations of B. bassiana using Mycotrol ESO and adult oviposition behavior to analyze the egg-laying preferences of wild Ae. albopictus in response to different fungal concentrations. We examined the mortality of mid-instars exposed to B. bassiana concentrations of 1 × 104, 1 × 105, 1 × 106, 1 × 107, and 1 × 108 conidia/ml every 24 h for 12 d. In the oviposition behavior study, the fungus was applied to wooden paddles at 1 × 105, 1 × 107, and 1 × 109 conidia/ml, and the paddles were individually placed into quad-ovitraps. Both experiments contained control groups without B. bassiana. Kaplan-Meier survival analysis revealed that larval mortality was concentration dependent. The median lethal concentration was 2.43 × 105 conidia/ml on d 12. The median lethal time was 3.68 d at 1 × 106 conidia/ml. Oviposition monitoring revealed no significant difference in egg count between the control and treatment paddles. We observed an inverse relationship between the concentration of B. bassiana and the percentage of paddles with eggs. We concluded that concentrations above 1 × 106 conidia/ml are larvicidal, and Ae. albopictus laid similar numbers of eggs on fungus-impregnated and control wooden substrates; however, they were more likely to oviposit on substrates without B. bassiana. With these findings, we suggest that B. bassiana-infused ovitraps can be used for mosquito population monitoring while also delivering mycopesticides to adult mosquitoes., (© The Author(s) 2022. Published by Oxford University Press on behalf of Entomological Society of America.)

Background: Anterior shoulder joint capsule thickening is typically present in osteoarthritic shoulders, but its association with specific patterns of glenoid wear is incompletely understood. We sought to determine the relationship between anterior capsular thickening and glenoid deformity in primary glenohumeral osteoarthritis., Methods: We retrospectively identified 134 consecutive osteoarthritic shoulders with magnetic resonance imaging and computed tomography scans performed. Axial fat-suppressed magnetic resonance imaging slices were used to quantify the anterior capsular thickness in millimeters, measured at its thickest point below the subscapularis muscle. Computed tomography scans were used to classify glenoid deformity according to the Walch classification, and an automated 3-dimensional software program provided values for glenoid retroversion and humeral head subluxation. Multinomial and linear regression models were used to characterize the association of anterior capsular thickening with Walch glenoid type, glenoid retroversion, and posterior humeral head subluxation while controlling for patient age and sex., Results: The anterior capsule was thickest in glenoid types B2 (5.5 mm, 95% confidence interval [CI]: 5.0-6.0) and B3 (6.1 mm, 95% CI: 5.6-6.6) and thinnest in A1 (3.7 mm, 95% CI: 3.3-4.2; P < .001). Adjusted for age and sex, glenoid types B2 (odds ratio: 4.4, 95% CI: 2.3-8.4, P < .001) and B3 (odds ratio: 5.4, 95% CI: 2.8-10.4, P < .001) showed the strongest association with increased anterior capsule thickness, compared to glenoid type A1. Increased capsular thickness correlated with greater glenoid retroversion (r = 0.57; P < .001) and posterior humeral head subluxation (r = 0.50; P < .001). In multivariable analysis, for every 1-mm increase in anterior capsular thickening, there was an adjusted mean increase of 3.2° (95% CI: 2.4-4.1) in glenoid retroversion and a 3.8% (95% CI: 2.7-5.0) increase in posterior humeral head subluxation., Conclusions: Increased thickening of the anterior shoulder capsule is associated with greater posterior glenoid wear and humeral head subluxation. Additional research should determine whether anterior capsular disease plays a causative role in the etiology or progression of eccentric glenohumeral osteoarthritis., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Reverse shoulder arthroplasty (RSA) is increasingly being utilized for the treatment of primary osteoarthritis. However, limited data are available regarding the outcomes of RSA as compared with anatomic total shoulder arthroplasty (TSA) in the setting of osteoarthritis., Methods: We performed a retrospective matched-cohort study of patients who had undergone TSA and RSA for the treatment of primary osteoarthritis and who had a minimum of 2 years of follow-up. Patients were propensity score-matched by age, sex, body mass index (BMI), preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative active forward elevation, and Walch glenoid morphology. Baseline patient demographics and clinical outcomes, including active range of motion, ASES score, Single Assessment Numerical Evaluation (SANE), and visual analog scale (VAS) for pain, were collected. Clinical and radiographic complications were evaluated., Results: One hundred and thirty-four patients (67 patients per group) were included; the mean duration of follow-up (and standard deviation) was 30 ± 10.7 months. No significant differences were found between the TSA and RSA groups in terms of the baseline or final VAS pain score (p = 0.99 and p = 0.99, respectively), ASES scores (p = 0.99 and p = 0.49, respectively), or SANE scores (p = 0.22 and p = 0.73, respectively). TSA was associated with significantly better postoperative active forward elevation (149° ± 13° versus 142° ± 15°; p = 0.003), external rotation (63° ± 14° versus 57° ± 18°; p = 0.02), and internal rotation (≥L3) (68.7% versus 37.3%; p < 0.001); however, there were only significant baseline-to-postoperative improvements in internal rotation (gain of ≥4 levels in 53.7% versus 31.3%; p = 0.009). The overall complication rate was 4.5% (6 of 134), with no significant difference between TSA and RSA (p = 0.99). Radiolucent lines were observed in association with 14.9% of TSAs, with no gross glenoid loosening. One TSA (1.5%) was revised to RSA for the treatment of a rotator cuff tear. No loosening or revision was encountered in the RSA group., Conclusions: When performed for the treatment of osteoarthritis, TSA and RSA resulted in similar short-term patient-reported outcomes, with better postoperative range of motion after TSA. Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H24 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Limited clinical evidence is available to help to predict poor outcomes after reverse shoulder arthroplasty (RSA) among patients with massive rotator cuff tears without glenohumeral arthritis. A retrospective case-control study was performed for patients who underwent RSA for massive rotator cuff tear without glenohumeral arthritis (Hamada score ≤3) and had a minimum of 2 years of follow-up. Preoperative risk factors for poor outcomes were subsequently analyzed. Sixty patients (mean age, 71.4±7.4 years) met the inclusion criteria. Of these, 18 (30%) patients had poor outcomes (case group). The case group had significantly worse postoperative Single Assessment Numeric Evaluation (SANE) (61.6±29.5 vs 84.9±14.1, respectively; P =.002), American Shoulder and Elbow Surgeons (58.9±22.5 vs 82.2±14.2, respectively; P <.001), and Simple Shoulder Test (5.4±3.6 vs 8.5±2.4, respectively; P =.002) scores compared with the control group. Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7, respectively; P =.021). The results of this study suggest that patients with better overall preoperative function, as represented by higher SANE scores, have a greater likelihood of poor functional outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis. For these patients, alternative treatment options should be considered. [ Orthopedics . 2022;45(4):215-220.].

Background: As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed., Questions/purposes: We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?, Methods: The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112])., Results: The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19])., Conclusion: There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty., Clinical Relevance: Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

The Asian tiger mosquito, Aedes albopictus (Skuse), is a public health threat because it can potentially transmit multiple pathogenic arboviruses, exhibits aggressive diurnal biting, and is highly invasive. As Ae. albopictus moved northward into the United States, the limits of expansion were predicted as locations with a mean January temperature warmer than -2.5°C. We postulated that the range of Ae. albopictus could exceed these temperature limits if eggs in diapause overwinter in tires that provide an insulating effect from extreme temperatures. Fifteen tires with Ae. albopictus and Aedes triseriatus (Say) eggs, a native cold hardy species, were placed outside at five locations along a latitudinal gradient in Wisconsin and Illinois during the winter of 2018-2019; notably, in January 2019, a regional arctic air event brought the lowest temperatures recorded in over 20 yr. External and internal tire temperatures were recorded at 3 hr intervals, and egg survival was recorded after six months. Aedes albopictus eggs survived only from tires at northernmost locations. The mean internal January temperature of tires that supported survival was -1.8°C, while externally the mean temperature was -5.3°C, indicating that tires provided an average of +3.5°C of insulation. Tires that supported egg survival also had over 100 mm of snow cover during January. In the absence of snow cover, tires across the study area provided an average +0.79°C [95% CI 0.34-1.11] insulation. This work provides strong argument for the inclusion of microhabitats in models of dispersal and establishment of Ae. albopictus and other vector species., (© The Author(s) 2022. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA., Methods: A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables., Results: Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P < .001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P > .05)., Conclusion: Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The management of recurrent instability after arthroscopic Bankart repair remains challenging. Of the various treatment options, arthroscopic revision repairs are of increasing interest due to improved visualization of pathology and advancements in arthroscopic techniques and instrumentation., Purpose: We sought to assess the indications, techniques, outcomes, and complications for patients undergoing revision arthroscopic Bankart repair after a failed index arthroscopic soft-tissue stabilization for anterior shoulder instability., Methods: We performed a systematic review of studies identified by a search of Medline, Embase, and PubMed. Our search range was from data inception to April 29, 2020. Outcomes include clinical outcomes and rates of complication and revision. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively., Results: Twelve studies were identified, comprising 279 patients (281 shoulders) with a mean age of 26.1 ± 3.8 years and a mean follow-up of 55.7 ± 24.3 months. Patients had improvements in postoperative outcomes (eg, pain and function). The overall complication rate was 29.5%, the most common being recurrent instability (19.9%)., Conclusion: With significant improvements postoperatively and comparable recurrent instability rates, there exists a potential role in the use of revision arthroscopic Bankart repair where the glenoid bone loss is less than 20%. Clinicians should consider patient history and imaging findings to determine whether a more rigorous stabilization procedure is warranted. Large prospective cohorts with long-term follow-up and improved documentation are required to determine more accurate failure rates., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ajaykumar Shanmugaraj, BHSc, Seaher Sakha, Tushar Tejpal, BHSc, Timothy Leroux, MD, MEd, Jacob M Kirsch, MD, and Moin Khan, MD, MSc, FRCSC declare they have no conflicts of interest., (© The Author(s) 2021.)

Introduction: The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA)., Methods: This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes., Results: Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P < 0.01), external rotation (54.2° versus 43.8°; P < 0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P < 0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P < 0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P < 0.01), and visual analog scale scores (0.63 versus 1.2; P < 0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P < 0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P < 0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P < 0.01)., Conclusion: RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA., Level of Evidence: Level III Therapeutic Study., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Muscle atrophy (MA) and fatty infiltration (FI) are degenerative processes of the rotator cuff musculature that have incompletely understood relationships with the development of eccentric glenoid wear in the setting of primary glenohumeral osteoarthritis (GHOA)., Methods: All patients with GHOA and an intact rotator cuff who underwent both magnetic resonance imaging and computed tomography scans of the affected shoulder prior to total shoulder arthroplasty between 2015 and 2020 were identified from a prospectively maintained registry. Rotator cuff MA was measured quantitatively on sequential sagittal magnetic resonance images, whereas FI was assessed on sagittal magnetic resonance imaging slices using the Goutallier classification. Preoperative computed tomography scans were reconstructed using automated 3-dimensional software to determine glenoid retroversion, glenoid inclination, and humeral head subluxation. Glenoid deformity was classified according to the Walch classification. Univariate and multivariable regression analyses were performed to characterize associations between age, sex, muscle area, FI, and glenoid morphology., Results: Among the 127 included patients, significant associations were found between male sex and larger overall rotator cuff musculature (P < .01), increased ratio of the posterior rotator cuff (PRC) to the subscapularis area (P = .01), and glenoid retroversion (19° vs. 14°, P < .01). Larger supraspinatus and PRC muscle size was correlated with increased retroversion (r = 0.23 [P = .006] for supraspinatus and r = 0.25 [P = .004] for PRC) and humeral head subluxation (r = 0.25 [P = .004] for supraspinatus and r = 0.28 [P = .001] for PRC). The ratio of PRC muscle size to anterior rotator cuff muscle size was not associated with evidence of eccentric glenoid wear (P > .05). After we controlled for confounding factors, increasing glenoid retroversion was associated with high-grade infraspinatus FI (β, 6.8; 95% confidence interval, 2.9-10.7; P < .01) whereas larger PRC musculature was predictive of a Walch type B (vs. type A) glenoid (odds ratio, 1.3; 95% confidence interval, 1.0-1.5; P = .04)., Conclusion: Patients with eccentric glenoid wear in the setting of primary GHOA and an intact rotator cuff appear to have both larger PRC musculature and higher rates of infraspinatus FI. Although the temporal and causal relationships of these associations remain ambiguous, MA and FI should be considered 2 discrete processes in the natural history of GHOA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Favorable clinical and functional outcomes can be achieved with reverse total shoulder arthroplasty (RSA). Given the expanding utilization of RSA in the United States, understanding the factors that influence both excellent and poor outcomes is increasingly important., Methods: A single-surgeon prospective registry was used to identify patients who underwent RSA from 2015 to 2018 with a minimum of 2 years' follow-up. An excellent postoperative clinical outcome was defined as a final American Shoulder and Elbow Surgeons (ASES) score in the top quartile of ASES scores. A poor outcome was defined as an ASES score in the bottom quartile. Logistic regression was used to determine preoperative characteristics associated with both excellent and poor outcomes., Results: A total of 338 patients with a mean age of 71.5 years (standard deviation [SD], 6.4 years) met the inclusion and exclusion criteria. The average preoperative ASES score for the entire cohort was 35.3 (SD, 16.4), which improved to 82.4 (SD, 16.1) postoperatively (P < .001). Univariate analysis demonstrated that a diagnosis of primary osteoarthritis (OA), private insurance, and higher preoperative ASES scores were significantly associated with achieving excellent outcomes (P < .01 for all). Variables predictive of poor outcomes were workers' compensation status (P = .03), depression (P = .02), a preoperative diagnosis of rotator cuff tear arthropathy (P < .01), preoperative opioid use (P < .01), a higher number of allergies (P < .01), and prior ipsilateral shoulder surgery (P < .01). Multivariate regression analysis demonstrated that OA (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2-26.5; P = .03) and private insurance (OR, 2.7; 95% CI, 1.12-6.5; P = .02) correlated with excellent outcomes whereas a higher number of reported allergies (OR, 0.83; 95% CI, 0.71-0.97; P = .02), self-reported depression (OR, 0.39; 95% CI, 0.16-0.99; P =.04), a history of ipsilateral shoulder surgery (OR, 0.36; 95% CI, 0.15-0.87; P =.02), and preoperative opioid use (OR, 0.26; 95% CI, 0.09-0.76; P = .01) were predictive of poor outcomes., Conclusions: A preoperative diagnosis of primary OA is the strongest predictor of excellent clinical outcomes following RSA. Patients with an increasing number of reported allergies, self-reported depression, a history of ipsilateral shoulder surgery, and preoperative opioid use are significantly more likely to achieve poor outcomes after RSA. Given the increasing utilization of RSA, this information is important to appropriately counsel patients regarding postoperative expectations., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs., Methods: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores., Results: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001)., Conclusions: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The impact of surgical timing on outcomes involving traumatic rotator cuff tears (RCTs) remains uncertain. The purpose of this study was to determine how functional outcomes are affected by surgical timing in traumatic RCTs., Methods: We performed a retrospective review of patients with repair of traumatic full-thickness RCTs. Preoperative magnetic resonance imaging scans were evaluated by 2 blinded reviewers to measure RCT area and muscular atrophy. Functional outcomes were assessed via the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Simple Shoulder Test score, and visual analog scale (VAS) pain score. Patients were divided into 4 groups based on the time from injury to surgery: 0-2 months (group 1), 2-4 months (group 2), 4-6 months (group 3), and 6-12 months (group 4). Multivariate analysis was performed to assess the impact of surgical timing on functional outcomes. A subanalysis was performed to assess outcomes in patients who underwent surgery within 3 weeks of injury., Results: The study included 206 patients (150 men and 56 women) with a mean age of 60.0 ± 9.7 years and a minimum of 24 months' clinical follow-up (mean, 35.5 months; range, 24-54.4 months). The average tear area was 8.4 ± 6.3 cm 2 in group 1 (66 patients), 5.8 ± 5.1 cm 2 in group 2 (76 patients), 5.1 ± 4.6 cm 2 in group 3 (29 patients), and 3.7 ± 3.1 cm 2 in group 4 (35 patients) (P < .001). There were significant differences between the 4 cohorts in the final postoperative ASES score (P = .030) and VAS pain score (P = .032). The multivariate regression demonstrated that patients who underwent surgery within 4 months of injury had estimated improvements of 10.3 points in the ASES score (P = .008), 1.8 points in the Simple Shoulder Test score (P = .001), 8.6 points in the SANE score (P = .033), and 0.93 points in the VAS pain score (P = .028) compared with patients who underwent surgery later. The subanalysis demonstrated that patients who underwent surgery within 3 weeks of injury (n = 13) had significantly better VAS (P = .003), ASES (P = .008), and SANE (P = .019) scores than patients who underwent surgery at between 3 weeks and 4 months after injury (n = 129)., Conclusions: This study demonstrates that surgical repair of traumatic RCTs results in significant improvements in functional outcomes for all patients; however, patients who undergo surgery within 3 weeks can expect the best functional outcomes, with a drop in function in patients who undergo surgery >4 months after injury., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Hypothesis: The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component., Methods: Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation., Results: Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment., Conclusion: Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Arthroscopic debridement is an effective means of surgical management of both degenerative osteoarthritis (DOA) and posttraumatic arthritis (PTA) of the elbow. However, the difference in the efficacy and longevity of this procedure when performed for these two distinct pathologies remains in question. The purpose of this study was to identify and compare the midterm outcomes and survivorship of arthroscopic debridement of elbow PTA and DOA., Methods: A retrospective analysis of patients undergoing arthroscopic debridement of DOA and PTA of the elbow was performed. A questionnaire containing the Oxford Elbow Score, as well as questions regarding the incidence of reoperation, additional nonoperative intervention, complications, pain, and satisfaction, was given at 5 years, minimum, after surgery. The midterm survivorship of arthroscopic debridement free of reoperation for any reason, as well as the remaining outcome measurements obtained via the questionnaire and in-office evaluation, was compared between PTA and DOA cohorts., Results: Eighty patients (DOA = 36, PTA = 44) were included in this study for analysis. All 36 patients with DOA were noted to be male. Follow-up time at the date of questionnaire response was 7.9 years (range, 5.6-11.8) in the DOA cohort and 8.6 years (range, 5.7-12.7) in the PTA cohort. Reoperation rates of 5.6% and 11.4% were identified in the DOA and PTA cohorts, respectively. No statistical difference was noted in reoperation rate, survivorship, or any measured patient-reported outcomes between cohorts at the final follow-up visit. Both cohorts demonstrated a significant improvement in Visual Analog Scale pain scores ( P  < .001) and ROM. Postoperative ROM was obtained at the final clinic visit at an average follow-up duration of 151 days and 255 days in the DOA and PTA cohorts, respectively. However, no difference in the degree of improvement in either outcome variable was identified after a comparison between cohorts., Conclusion: Arthroscopic debridement is an equally efficacious treatment option for DOA and PTA of the elbow. Patients with either pathology can expect satisfactory elbow function and an improvement in pain with little chance of reoperation at the midterm of the follow-up duration., (© 2021 The Author(s).)

Bacteria and their viruses (bacteriophages or phages) interact antagonistically and beneficially in polymicrobial communities such as the guts of animals. These interactions are multifaceted and are influenced by environmental conditions. In this review, we discuss phage-bacteria interactions as they relate to the complex environment of the gut. Within the mammalian and invertebrate guts, phages and bacteria engage in diverse interactions including genetic coexistence through lysogeny, and phages directly modulate microbiota composition and the immune system with consequences that are becoming recognized as potential drivers of health and disease. With greater depth of understanding of phage-bacteria interactions in the gut and the outcomes, future phage therapies become possible.

Competing Interests: The authors declare no conflict of interest.

Background: Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR)., Methods: Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery., Results: A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05)., Conclusion: Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)