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Anatomic total shoulder arthroplasty (aTSA) is a successful and reproducible treatment for patients with painful glenohumeral arthritis. However, long-term outcomes using traditional onlay glenoid components have been tempered by glenoid loosening. Inset components have been proposed to minimize glenoid loosening by reducing edge-loading and opposite-edge lift-off forces with humeral translation. Successful short and long-term outcomes have been reported while using inset glenoid implants. The current study is the largest study presenting a minimum of two-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI).A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by two fellowship-trained shoulder surgeons at two separate institutions from August, 2016 to August, 2019 was performed. Minimum follow up was two years. Range of motion (ROM), Visual Analog Pain Scores (VAS), Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores were obtained. Radiographic outcomes, including central peg lucency and glenoid loosening, were assessed by three independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up.Seventy-five shoulders were included for final analysis. The mean age of the entire cohort was 64 (±11.4) years. Twenty-one (28%) glenoids were type A1, 10 (13.3%) were type A2, 13 (17.3%) were type B1, 22 (29.3%) were type B2, six (8%) were type B3 and three (4%) were type D. At a minimum follow-up of 24 months (mean 28.7 months), a significant improvement in ROM in all planes was observed. Significant improvements in VAS (5.1 to 0.9, p0.001), SANE (39.5 to 91.2, p0.001) and ASES (43.7 to 86.6, p0.001) scores were observed. There were four (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) cases of glenoid loosening. No revisions were performed for glenoid loosening.At a minimum of two years postoperatively, there were significant improvements in ROM and VAS, SANE, and ASES scores with very low rates of central peg lucency and glenoid loosening in patients undergoing aTSA with an inset glenoid component. Further work is needed to determine the long-term benefit of this novel implant.

Hypothesis/Purpose The objective is to develop and validate an artificial intelligence model, specifically an artificial neural network (ANN), to predict length of stay (LOS), discharge disposition, and inpatient charges for primary anatomic total (aTSA), reverse total (rTSA), and hemi- (HSA) shoulder arthroplasty to establish internal validity in predicting patient-specific value metrics. Methods Using data from the National Inpatient Sample between 2003 and 2014, 4 different ANN models to predict LOS, discharge disposition, and inpatient costs using 39 preoperative variables were developed based on diagnosis and arthroplasty type: primary chronic/degenerative aTSA, primary chronic/degenerative rTSA, primary traumatic/acute rTSA, and primary acute/traumatic HSA. Models were also combined into diagnosis type only. Outcome metrics included accuracy and area under the curve (AUC) for a receiver operating characteristic curve. Results A total of 111,147 patients undergoing primary shoulder replacement were included. The machine learning algorithm predicting the overall chronic/degenerative conditions model (aTSA, rTSA) achieved accuracies of 76.5%, 91.8%, and 73.1% for total cost, LOS, and disposition, respectively; AUCs were 0.75, 0.89, and 0.77 for total cost, LOS, and disposition, respectively. The overall acute/traumatic conditions model (rTSA, HSA) had accuracies of 70.3%, 79.1%, and 72.0% and AUCs of 0.72, 0.78, and 0.79 for total cost, LOS, and discharge disposition, respectively. Conclusion Our ANN demonstrated fair to good accuracy and reliability for predicting inpatient cost, LOS, and discharge disposition in shoulder arthroplasty for both chronic/degenerative and acute/traumatic conditions. Machine learning has the potential to preoperatively predict costs, LOS, and disposition using patient-specific data for expectation management between health care providers, patients, and payers.

Oxygen uptake (V̇o 2 ) at exercise onset is determined in part by acceleration of pulmonary blood flow ([Formula: see text]). Impairments in the [Formula: see text] response can decrease exercise tolerance. Prior research has shown that voluntary respiratory maneuvers can augment venous return, but the corollary impacts on cardiac function, [Formula: see text] and early-exercise V̇o 2 remain uncertain. We examined 1) the cardiovascular effects of three distinct respiratory maneuvers (abdominal, AB; rib cage, RC; and deep breathing, DB) under resting conditions in healthy subjects (Protocol 1, n = 13), and 2) the impact of pre-exercise DB on pulmonary O 2 transfer during initiation of moderate-intensity exercise (Protocol 2, n = 8). In Protocol 1, echocardiographic analysis showed increased right ventricular (RV) cardiac output and left ventricular (LV) cardiac output (RVCO and LVCO, respectively), following AB (by +23 ± 13 and +18 ± 15%, respectively, P < 0.05), RC (+23 ± 16; +14 ± 15%, P < 0.05), and DB (+27 ± 21; +23 ± 14%, P < 0.05). In Protocol 2, DB performed for 12 breaths produced a pre-exercise increase in V̇o 2 (+801 ± 254 mL·min -1 over ∼6 s), presumably from increased [Formula: see text], followed by a reduction in pulmonary O 2 transfer during early phase exercise (first 20 s) compared with the control condition (149 ± 51 vs. 233 ± 65 mL, P < 0.05). We conclude that 1) respiratory maneuvers enhance RVCO and LVCO in healthy subjects under resting conditions, 2) AB, RC, and DB have similar effects on RVCO and LVCO, and 3) DB can increase [Formula: see text] before exercise onset. These findings suggest that pre-exercise respiratory maneuvers may represent a promising strategy to prime V̇o 2 kinetics and thereby to potentially improve exercise tolerance in patients with impaired cardiac function.NEW & NOTEWORTHY We demonstrate that different breathing maneuvers can augment both right and left-sided cardiac output in healthy subjects. These maneuvers, when performed immediately before exercise, result in a pre-exercise "cardiodynamic" increase in oxygen uptake (V̇o 2 ) associated with a subsequent reduction in the "cardiodynamic" V̇o 2 normally seen during early exercise. We conclude that pre-exercise breathing maneuvers are a plausible tool worthy of additional study to prime V̇o 2 kinetics and improve exercise tolerance in patients with cardiovascular disease.

Background: Failure to recognize a potential wrist arthrotomy may lead to missed septic arthritis and devastating sequelae. The saline load test is routinely used to recognize traumatic arthrotomies of other joints; however, there are limited data optimizing this test for the wrist. The purpose of this study was to investigate and perform saline load testing to identify traumatic arthrotomies of the wrist. Methods: This was a cadaveric study of 15 wrists. Traumatic arthrotomies were created using a blunt trocar through the 3-4 portal. A 3-mL syringe with 0.1 mL markings was used to inject methylene blue dyed saline into the wrist through the 1-2 portal. Once extravasation was visible from the atherectomized site, the volume was recorded. Results: The mean (range) volume injected to identify the arthrotomy of all wrists was 1.22 mL (range, 0.1-3.1 mL). Multivariate regression demonstrated that cadaver age, laterality, and extension range of motion were not significantly associated with the injected saline volume at extravasation ( P > .05, each). Greater joint range of motion was independently associated with higher saline volume load for extravasation (odds ratio: 1.049; 95% confidence interval: 1.024-1.075; P = .003). Conclusions: We found that 2.68 and 3.02 mL of methylene blue dyed saline offered 95% and 99% sensitivity, respectively, for diagnosing traumatic wrist arthrotomy. The maximum volume of saline needed to recognize an arthrotomy was 3.1 mL. We recommend this be the minimum volume used to evaluate a traumatic wrist arthrotomy.

The purpose of this study was to examine the relationship between elevated preoperative international normalized ratio (INR) and (1) mortality, (2) postoperative bleeding, and (3) other postoperative complications in a national cohort of patients who underwent revision total knee arthroplasty (rTKA). The American College of Surgeons National Surgical Quality Improvement Program was queried for rTKA procedures conducted between 2006 and 2017. Cohorts were based on INR ranges: 1.5. Univariate/multivariate statistics were calculated to analyze associations between INR value and designated covariates. These statistics were additionally applied to optimal cutoff values of INR calculated using a receiver operating characteristics curve. The final cohort consisted of 1,676 patients. Progressively higher INR values were associated with an increased risk of mortality within 30 days (p

Hip fractures and metabolic syndrome (MetS) are becoming major global healthcare burdens as populations age. This study sought to determine the impact of MetS in hip fracture patients on perioperative outcomes following operative fixation or arthroplasty.Data from the 2004-2014 Nationwide Inpatient Sample was used to select 3,348,207 discharges with hip fracture. MetS patients were identified by having at least 3 of 4 component comorbidities: hypertension, dyslipidemia, obesity, and diabetes. Logistic regression was used to estimate odds ratios for the association between MetS and perioperative outcomes adjusted for age, gender, race, payer status, and comorbidities.Overall, 32% of hip fracture patients were treated with open reduction internal fixation (ORIF), 28% hemiarthroplasty (HA), 18% closed reduction with internal fixation (CRPP), and 3% primary total hip arthroplasty (THA). The remaining 19% of cases were either treated via unspecified procedure of hip repair (9%), managed non-operatively (2%), underwent multiple procedures during the hospital stay (6%), or the surgical procedure data was missing (2%) and were excluded from procedural analyses. The prevalence of MetS was 7.9% and increased among minorities, patients treated at urban hospitals, with comorbidities (heart failure, kidney disease, peripheral vascular disease), and with Medicare coverage. MetS was associated with increased odds of any adverse event (p 0.0001), specifically: acute renal failure, myocardial infarction, acute posthemorrhagic anemia. MetS was also associated with increased LOS (p 0.0001) and increased total charges (p 0.0001). However, MetS was associated with reduced odds of postoperative pneumonia, deep vein thrombosis and pulmonary embolism, surgical site infection, septicemia, and in-hospital mortality (p 0.0001). The above associations were maintained for MetS patients stratified according to their treatment groups: HA, CRPP, and ORIF.MetS is associated with increased odds of complications in hip fracture patients but decreased odds of in-hospital mortality. This may be related to patients' nutritional status and catabolic states in the perioperative period.

Background: The saline load test is routinely used to recognize other joints’ traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. Methods: This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. Results: The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation( P > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Conclusions: Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.

Proper femoral component alignment in the axial plane during total knee arthroplasty (TKA) depends on accurate bone cuts and soft tissue balancing. Two methods that are used to achieve this are “measured resection” and “gap balancing.” However, a controversy exists as to which method is more accurate and leads to better outcomes. Therefore, the purpose of this study was to evaluate: (1) implant survivorship, (2) patient outcomes, (3) complications, and (4) radiographic analysis comparing patients who underwent TKA with either gap-balancing or measured resection techniques. A total of 214 consecutive patients (221 knees) underwent primary TKA by a single surgeon between 2011 and 2012. Component alignment was achieved by using measured resection in 116 knees and gap balancing was used in 105 knees. The patients had a mean age of 66 years (range, 44–86 years) and a mean body mass index of 32 kg/m2 (range, 22–52 kg/m2). Patient range-of-motion (ROM) and Knee Society (KS) function and pain scores, and radiographic assessment, were assessed preoperatively and postoperatively at ∼6 weeks, 3 months, 1 year, and then annually. The mean follow-up time was 3 years. A Kaplan–Meier's analysis was performed to calculate the survivorship. The aseptic survivorship was 98% in both the measured resection and gap-balancing groups. The mean ROM was not significantly different between the measured resection and gap-balancing groups (123 vs. 123 degrees, p = 0.990). There were no significant differences between the two groups in terms of the KS function scores (86 vs. 85 points, p = 0.829) or the KS pain scores (93 vs. 92 points, p = 0.425). Otherwise, the radiographic evaluation at latest follow-up did not demonstrate any evidence of progressive radiolucencies or loosening, of any prosthesis. The results of this study found that at a mean follow-up of 3 years, both the measured resection and gap-balancing techniques achieved excellent survivorship and postoperative outcomes. This demonstrates that both methods can be used to achieve accurate femoral component alignment with similar short-term outcomes.

Background: It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture. Purpose: To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee. Study Design: Case series; Level of evidence, 4. Methods: A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively. Results: At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports. Conclusion: The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee.

Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.

Multiple studies have shown tranexamic acid (TXA) to reduce blood loss and transfusion rates in patients undergoing total knee arthroplasty (TKA). Accordingly, TXA has become a routine blood conservation agent for TKA. In contrast, ε-aminocaproic acid (EACA), a similar acting antifibrinolytic to TXA, has been less frequently used. This study evaluated whether EACA is as efficacious as TXA in reducing postoperative blood transfusion rates and compared the cost per surgery between agents. A multicenter retrospective chart review of elective unilateral TKA from April 2012 through December 2014 was performed. Five hospitals within a health care system participated. Data collected included age, gender, severity of illness score, use of antifibrinolytic and dose, red blood cell (RBC) transfusions and the number of units, and preadmission and discharge hemoglobin (Hb). Dosing of the antifibrinolytic differed based on the agent used, 5 or 10 g (based on weight) for EACA versus 1 g for TXA. The institutional acquisition cost of each antifibrinolytic was obtained and averaged over the study period. Of 2,922 primary unilateral TKA cases, 820 patients received EACA, 610 patients received TXA, and 1,492 patients received no antifibrinolytic (control group). Compared with the control group both EACA and TXA groups had significantly fewer patients transfused (EACA 2.8% [p

BACKGROUND We aimed to explore the effect of body mass index (BMI) on 30-day complications after aseptic revision total knee arthroplasty (rTKA) and aseptic revision total hip arthroplasty (rTHA), considering BMI as both a categorical and continuous variable. METHODS A total of 18,866 patients (9093 rTHA and 9773 rTKA) patients were included for analysis using the American College of Surgeons National Surgical Quality Improvement Project database. Thirty-day rates of readmissions, reoperations, and major and minor complications were compared between different weight categories (overweight: BMI >25 and ≤30 kg/m2; obese: BMI >30 and ≤40 kg/m2; morbidly obese: BMI >40 kg/m2) and the normal weight category (BMI >18.5 and ≤25 kg/m2) using multivariate regression models. Spline regression models were created to study BMI as a continuous variable. RESULTS Both readmission rates and reoperation rates increased for rTKA as BMI increased (P < .005). There was a linear relationship between BMI and readmission rates for rTKA. Morbid obesity was associated with an increased reoperation rate for rTHA on univariate analysis (P = .022); however, multivariate analysis showed no statistically significant increase in readmission or reoperation rates as BMI increased for rTHA. CONCLUSIONS The relationship between BMI and complications after revision total joint arthroplasty is a J-shaped curve with the lowest rates of complications occurring around a BMI of 30 kg/m2. The relationship between BMI and perioperative complications is stronger for revision TKA as opposed to revision THA.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). SUMMARY OF BACKGROUND DATA Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. METHODS A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. RESULTS Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ± 2 vs. 7 ± 2 levels, P

Background: Although arthroscopy is generally considered to be a relatively benign procedure with limited trauma to periarticular soft tissues, post-arthroscopic bleeding as well as osmolality differences between the normal saline used to irrigate and the native synovial fluid (282 vs . 420 mOs) can lead to capsular reactions. Therefore, the purpose of this study was to evaluate whether capsular reaction occurred after knee arthroscopy, by comparing a matched cohort of patients who either did or did not undergo prior arthroscopic surgery. Specifically, we compared histological features such as: (I) synovial thickness; (II) cellularity; and (III) the amount of fibrous tissue for each cohort. Methods: Prior to their total knee arthroplasty (TKA), 40 consecutive patients who had previously undergone arthroscopy were matched to 40 consecutive patients who had not. During each patient’s TKA, a biopsy of the capsule and fat pad was taken and formalin sections were sent to pathology to assess for synovial thickness, cellularity, and the amount of fibrous tissue. The pathologist was blinded to the groupings. Findings for all histologic features were classified as equivocal, slight to moderate, and moderate to severe. Results: There were a significantly higher proportion of patients who had increased synovial thickness in the prior arthroscopy group as compared to the no-prior arthroscopy group (97.5% vs . 0%, P vs . 0%, P vs . 62.5%, P Conclusions: Arthroscopic surgery may have long-term effects on capsular tissue as surgical observations of patients with prior arthroscopic surgery from this study found that the capsule is thicker and denser. Histologic assessment confirms there may be increased synovial thickness, increased cellularity, as well as thickening of fibrous tissue. This preliminary study and further evaluation are required. This suggests that arthroscopic surgery may have long-lasting effects on periarticular tissue especially the capsular tissue which may have implications for pain and functional recovery.

Epilepsy is the most common serious neurological disorder in the United States, but little is known about its effect in the perioperative shoulder surgery setting. The authors sought to determine whether patients with epilepsy undergoing shoulder arthroplasty would be at increased risk for in-hospital adverse events, prolonged length of stay, and nonroutine disposition. Using the National Inpatient Sample (2002–2011), 422,371 adults undergoing shoulder arthroplasty were identified, 3714 (0.9%) of whom had epilepsy. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling. The authors found that patients with epilepsy were more likely to experience postoperative adverse events (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.54–1.84), including mechanical ventilation (OR, 3.91; 95% CI, 2.81–5.44), gastrointestinal complication (OR, 3.86; 95% CI, 2.78–5.37), deep venous thrombosis (OR, 3.23; 95% CI, 2.22–4.69), pneumonia (OR, 1.66; 95% CI, 1.35–2.04), posthemorrhagic anemia (OR, 1.57; 95% CI, 1.42–1.73), transfusion (OR, 1.56; 95% CI, 1.41–1.72), and acute renal failure (OR, 1.34; 95% CI, 1.04–1.74). An epilepsy diagnosis was also associated with increased odds for prolonged hospital stay (OR, 1.39; 95% CI, 1.28–1.52) and nonroutine discharge (OR, 1.80; 95% CI, 1.67–1.94). This study concludes that patients with epilepsy are at higher risk for early postoperative complications and resource use following shoulder arthroplasty surgery. Awareness of these risks may allow more targeted perioperative management of these patients to optimize postoperative outcomes and limit complications. [ Orthopedics. 2016; 39(6):e1075–e1079.]

xtensive blood loss after total knee arthroplasty (TKA) is common, and affected patients often require blood transfusions. Studies suggest that antifibrinolytic agents such as aminocaproic acid (ACA) reduce blood loss and blood transfusion rates in patients undergoing TKA. We conducted a study to evaluate whether a single intravenous 10-g dose of ACA given during primary unilateral TKA would decrease perioperative blood loss, raise postoperative hemoglobin levels, and reduce postoperative blood transfusion rates. We retrospectively reviewed the charts of 50 comparable cemented primary unilateral TKAs. Twenty-five patients had been given a single intraoperative 10-g dose of ACA (antifibrinolytic group), and the other 25 had not been given ACA (control group). Postoperative drain output was decreased significantly (P.0001) in the antifibrinolytic group (155 mL) compared with the control group (410 mL), as was the number of units of blood transfused after surgery (antifibrinolytic group, 0 units; control group, 10 units; P.002). There were no adverse events in the antifibrinolytic group. In TKA, perioperative blood loss and blood transfusion rates were reduced significantly in patients given a single intraoperative intravenous 10-g dose of ACA compared with patients not given antifibrinolytics. The positive effects of ACA were obtained without adverse events or complications.

Reverse total shoulder arthroplasty can restore forward elevation in pseudoparalytic shoulders, can reduce pain, and can increase quality of life for patients; however, there are a number of issues with regard to the design and ideal implantation technique of reverse total shoulder arthroplasties that remain controversial. Glenospheres with a Grammont, medialized center of rotation and designs with a more lateralized center of rotation have specific pros and cons. Medialized designs have historically decreased glenosphere loosening but increase scapular notching, and lateralized designs decrease notching and improve range of motion but historically have resulted in increased baseplate failure. As such, a concrete conclusion with regard to medialization or lateralization of the glenosphere cannot be made at this time. Caudal, inferior placement of the glenosphere increases internal rotation, external rotation, abduction, and adduction while reducing notching. Superior baseplate positioning and tilt are correlated with baseplate failure and therefore should be avoided. It remains unclear whether neutral or slightly inferior tilt is preferred. The ideal humerosocket inclination angle remains unclear. The 135[degrees] designs appear to have a lower rate of scapular notching than the Grammont-style 155[degrees] humerosockets. The implications of this angle for instability remain unclear as, to our knowledge, there have been no randomized comparisons and the largest meta-analysis was confounded by other implant variables.

Use of antifibrinolytic agents in total hip arthroplasty (THA) is well supported; however, most studies used tranexamic acid (TXA), whereas few used ε-aminocaproic acid (EACA), a similar antifibrinolytic. This study compares the efficacy and cost per surgery of intraoperative infusion of EACA and TXA in reducing postoperative blood transfusion rates in THA.Retrospective chart review of 1799 primary unilateral THA cases from April 2012 through December 2014 at 5 hospitals within our health care network.In our cohort, 711 received EACA, 445 received TXA, and 643 (control group) received no antifibrinolytic. Both antifibrinolytic groups had significantly fewer patients receiving red blood cell (RBC) transfusions when compared with control group (EACA 6.8% [P.0001], TXA 9.7% [P.0001] vs control group 24.7%). Average number of RBC units per patient were similar for EACA and TXA (0.11 units/patient and 0.15 units/patient, respectively), and both were significantly lower than the control group (0.48 units/patient, P.0001). No significant difference was noted in mean RBC units per patient and percentage of patients transfused between EACA and TXA groups (P = .144, P = .074). Logistic regression showed no difference between EACA and TXA when adjusting for age, gender, higher severity of illness levels, admission hemoglobin, performing surgeon, and hospital. Medication acquisition cost for EACA averaged $2.70 per surgery compared with TXA at $39.58 per surgery.Intraoperative antifibrinolytic use significantly decreases need for postoperative blood transfusions. At our institution, EACA is comparable to TXA in THA for reducing transfusion rates while at a lower cost per surgery.