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BACKGROUND Despite the routine use of plain radiographs to stratify the severity of glenohumeral osteoarthritis, little is known about the relationship between radiographic measures and patient-perceived pain and function. QUESTIONS/PURPOSES (1) What radiographic findings are associated with worse pain and function in patients with glenohumeral osteoarthritis? (2) What demographic factors are associated with worse pain and function in patients with glenohumeral osteoarthritis? METHODS This retrospective study included patients presenting for an initial office visit for primary glenohumeral osteoarthritis. Patients with other concurrent shoulder pathologic findings, prior surgery, lack of pain and functional scores, recent injection, or inadequate radiographs were excluded. Between January 2017 and January 2019, 3133 patients were eligible based on these inclusion criteria; 59% (1860) had outcome assessments and 48% (893) of those had radiographs. An additional 42% (378) of those with radiographs were excluded because of other shoulder findings, recent injection, prior surgery, or inadequate radiographs, leaving 16% (515 of 3133) who were fully analyzed in this study. A radiographic review included the joint space width, posterior humeral head subluxation, inferior humeral head osteophyte size, cystic change, and head asphericity. Additionally, radiographic arthritis was classified according to the Walch, Samilson-Prieto, and Kellgren-Lawrence classifications by two separate reviewers. Radiographic and demographic criteria as well as the presence of psychologic or mental illness were correlated with VAS Pain (range 1-10; minimal clinically important difference [MCID] 1.6), American Shoulder and Elbow Surgeons (ASES; range 0-100; MCID 13.6), Single Assessment Numeric Evaluation (SANE; range 0-100; MCID 14), and Simple Shoulder Test (SST; range 0-12; MCID 1.5) scores using univariate and multivariable regression analyses. RESULTS After accounting for age, gender, and psychologic illness in the multivariable analysis, we found that patients with Samilson-Prieto Grade 4 arthrosis had lower VAS Pain scores (β = -1.9; p = 0.02) than those with Grade 0 or 1 did; however, no clinically important associations were found between Samilson-Prieto Grade 4 and ASES (β = 7; p = 0.25), SANE (β = 4; p = 0.63), or SST (β = 0.5; p = 0.62) scores. No clinically important associations were found between Kellgren-Lawrence Grade 3 and VAS Pain (β = 1.4; p = 0.10), ASES (β = -8; p = 0.22), SANE (β = -13; p = 0.11), or SST scores (β = 0.4; p = 0.66). Radiographic joint space and posterior subluxation also did not have any clinically important associations with VAS Pain or functional scores. In assessing Walch glenoid type, there was no clinically important association between glenoid type and VAS Pain (F = 3.1; p < 0.01), ASES (F = 1.9; p = 0.15), SANE (F = 0.45; p = 0.66), or SST scores (F = 0.76; p = 0.71). Men had higher SST scores than women did (β = 2.0; p < 0.01), but there were no clinically important differences in VAS Pain (β = -0.4; p = 0.04), ASES (β = 6; p < 0.01), or SANE (β = 4; p = 0.07) scores. No clinically important association was found between age or the presence of any psychologic illness and VAS Pain or functional scores. CONCLUSION In patients with glenohumeral arthritis, no consistent clinically important differences in pain or function were discovered with respect to radiographic or demographic factors. Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity. Future studies can build on these findings by examining other non-radiographic or demographic factors that affect pain in patients with shoulder arthritis, such as psychological factors. LEVEL OF EVIDENCE Level III, prognostic study.

Total shoulder arthroplasty (TSA) and reverse TSA have provided an effective treatment for glenohumeral osteoarthritis; however, longevity of the procedure may be limited by osteolysis and polyethylene wear. In TSA, glenoid component failure occurs through several mechanisms, the most common being aseptic loosening and polyethylene wear. Newer bearing surfaces such as highly cross-linked ultra-high-molecular-weight polyethylene, vitamin E processing, ceramic heads, and pyrolytic carbon surfaces have shown improved wear characteristics in biomechanical and some early clinical studies. The purpose of this review is to provide a historical perspective and current state of the art of bearing surface technology in anatomic and reverse TSA.

We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities.This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status.Median duration of symptoms before surgery was significantly shorter in workers' compensation patients than in non-workers' compensation patients (47% less; P0.0001) and in men than in women (31% less; P0.001), but was not influenced by shareholder status or facility ownership (P0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non-physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P0.0001).The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons' practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery.Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons' use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non-physician-owned facilities and with nonshareholder physicians than with shareholder physicians.Level III.

Case A 58-year-old woman underwent successful reverse total shoulder arthroplasty for a proximal humerus fracture. Three years later, she sustained a periprosthetic humerus fracture after a fall and was treated conservatively. She healed with an abundance of callus and subsequently developed delayed-onset radial nerve palsy at 3 months, despite minimal change in humeral alignment and avoidance of the use of any compressive external braces or splints. Conclusions Minimally displaced periprosethetic humerus fractures can lead to delayed radial nerve palsy from callus entrapment, and there should be increased awareness of this potential complication when counseling and treating patients conservatively.

Radial head arthroplasty has joined the armamentarium of options for the treatment of complex radial head fractures, elbow instability, and arthritic conditions. A variety of implants has been introduced in the past decade; these differ in metallic composition, design, and method of fixation. Good short- and intermediate-term outcomes have been reported with the use of loose-fitting prostheses. Press-fit devices restore stability and improve pain and motion but are associated with a greater likelihood of implant loosening, leading to revision surgery. Postoperative elbow stiffness, pain, ulnar nerve palsy, posterior interosseous nerve palsy, and heterotopic ossification have all been reported following radial head surgery, but these complications are likely related to the trauma sustained by the elbow. Adequate knowledge of the surgical indications, types of implants, and surgical technique are essential for a satisfactory outcome when a radial head prosthesis is used for the treatment of nonreconstructable radial head fractures.

Revision total shoulder arthroplasty can be technically challenging. Results are inferior to those of primary arthroplasty, particularly when the indications for revision are related to soft-tissue problems. Patient selection is important. In the stiff arthroplasty, the surgeon must address rotator cuff and capsular contractures as well as exuberant soft-tissue adhesions. Unstable arthroplasty can be the result of asymmetric soft-tissue balancing or deficiencies (eg, subscapularis deficiency) that can lead to loss of the rotator cuff force couples and, subsequently, to instability on attempted glenohumeral motion. Infection must be considered in the workup of the failed total shoulder. In this era of ever-increasing use of shoulder arthroplasty, surgeons will be presented with growing numbers of patients who require revision surgery. An organized approach is needed to diagnose and manage the stiff or unstable total shoulder arthroplasty.

High levels of total cholesterol, triglycerides, and low-density lipoprotein are toxic to the vascular endothelium and thus have long been associated with atherosclerosis. Several clinical studies have suggested that elevated cholesterol also has a negative effect on tendon structure and function. Data from our preliminary studies show that the patellar tendons of hypercholesterolemic knockout mice exhibit reduced baseline elastic modulus and strength postinjury compared with controls.We therefore hypothesized elevated cholesterol would be associated with diminished tendon mechanical properties.Using hypercholesterolemic (B6.129P2-Apoetm1Unc/J) mice, patellar tendons from control (C57BL/6) and knockout mice will be injured surgically at two different times. Subsequently, mechanical testing will be performed and data evaluated for differences in baseline and in healing between cholesterol groups. For healing assessment, data from the injured limb of each animal will be normalized to that of the sham-operated contralateral limb.We anticipate that such studies eventually will enable us to elucidate the link between elevated cholesterol and tendon disease. If a mechanistic cause of hypercholesterolemia causing tendon disease is clarified, then potentially therapeutic interventions such as the use of pharmacotherapy may be used to help combat this. In the future, it may become worthwhile to consider the presentation of tendinopathy as a trigger to measure serum cholesterol just as one might consider measuring serum glucose in patients presenting with adhesive capsulitis.

BackgroundPartial distal biceps tears are difficult to diagnose clinically. The purpose of this study was to evaluate the accuracy of the direct radial tuberosity compression test in diagnosing partial distal biceps tendon avulsions.MethodsA consecutive series of 24 patients with partial distal bice

Early treatment of osteonecrosis of the femoral head yields better results than late treatment. Because osteonecrosis frequently is bilateral, it often is advisable to treat both hips simultaneously. Core decompression is one of the more common methods of treatment; however the safety of doing simultaneous bilateral core decompression has been questioned. We sought to evaluate the safety and effectiveness of simultaneous bilateral core decompression compared with unilateral core decompression. One hundred ninety-three patients (276 hips) who had core decompression with bone grafting were followed up for 24 to 145 months. One hundred twenty-four procedures were unilateral and 152 were bilateral. Patients were evaluated by change in Harris hip score, radiographic progression, postoperative complications, and conversion to total hip arthroplasty. Total hip arthroplasty was required in 56 of 124 (45%) of hips in the unilateral, and 48 of 152 (32%) of hips in the bilateral group. Postoperative complications were similar. In the unilateral group there were two major and nine minor complications; in the bilateral group there were three major and 10 minor complications. When bilateral core decompression is indicated, it can be done simultaneously on both hips, allowing earlier treatment of the contralateral hip without risk of increased complications and possibly with a better outcome. It requires only one hospitalization and decreases recovery time compared with two separate procedures. Therefore, it provides advantages over procedures that cannot be done simultaneously on both hips.Therapeutic study, Level IV (case series-no common or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Various mechanisms of injury to the triquetrum have been described, including rotational or twisting injuries1, shearing by impingement of the hamate on the posteroradial projection of the triquetrum2, impaction by the ulnar styloid3,4, falls with the wrist in extension and ulnar deviation2,5, and direct blows to the dorsum of the triquetrum1,2,6. In spite of the common nature of triquetral fractures, nonunion is an exceedingly rare complication. In fact, we identified only one other report of a triquetral body nonunion in our search of the literature7. The uncommon nature of this complication probably is explained by the rich blood supply to the triquetral body, which has extensive internal vascular networks and numerous intraosseous anastomoses8,9. We describe an unusual case of an isolated fracture of the triquetrum with a resultant painful nonunion that healed after surgical treatment. The patient was informed that data concerning her case would be submitted for publication. Atwenty-six-year-old, left-hand-dominant woman presented with pain in the left wrist. The symptoms had developed two months prior to presentation, several days after a motor-vehicle accident in which the patient had struck the dashboard …

When doing a proximal tibial prosthetic reconstruction, some surgeons think that the subcutaneous location of the proximal tibia necessitates a gastrocnemius muscle flap for closure and function. In this study, 22 patients with bone tumors had proximal tibial segmental prosthetic replacement using direct reattachment of the patellar tendon to the prosthesis without the use of a muscle flap. Two of 19 patients required reoperation in the postoperative period for hematomas. Both were free of infection or other complications at 24 months mean followup. No other wound complications occurred despite initiation of chemotherapy 2 to 3 weeks after surgery in patients with high-grade malignant tumors (15 of 19). The mean followup was 38.6 months (range, 13-99 months). The patients ranged in age from 15 to 74 years (mean, 39 years). The range of motion achieved postoperatively showed a mean of 97 degrees (+/-16.3 degrees). All patients had full passive extension with a mean extensor lag of 7.5 degrees. The mean Musculoskeletal Tumor Society score was 27.6 (+/- 2.0). These results of patients without muscle flaps compare favorably with published results advocating gastrocnemius flaps for the attachment of the patellar tendon to the prosthesis.

Anterior glenohumeral instability is a common, yet complicated orthopaedic disorder. During the past few years, basic science research has improved the understanding of the glenohumeral joint stabilizing systems. The current authors review new contributions specifically detailing study of the interplay between the static and dynamic restraints. Simulation of the shoulder muscles in a recent study also has manifested the powerful contribution of the joint reaction force to concavity-compression. Continued advances, such as these, will improve the understanding, and allow better outcome, in treatment of glenohumeral instability.

Many patients with rotator cuff tears have questions for their surgeons regarding the surgical procedure, perioperative management, restrictions, therapy, and ability to work after a rotator cuff repair. The purpose of our study was to determine common clinical practices among experts regarding rotator cuff repair and to assist them in counseling patients. We surveyed 372 members of the American Shoulder and Elbow Surgeons (ASES) and the Association of Clinical Elbow and Shoulder Surgeons (ACESS); 111 members (29.8%) completed all or part of the survey, and 92.8% of the respondents answered every question. A consensus response (>50% agreement) was achieved on 49% (24 of 49) of the questions. Variability in responses likely reflects the fact that clinical practices have evolved over time based on clinical experience.