Publications by authors named "Brian C Werner"

282 Publications

The addition of preoperative three-dimensional analysis alters implant choice in shoulder arthroplasty.

Shoulder Elbow 2022 Aug 1;14(4):378-384. Epub 2021 Feb 1.

Hospital for Special Surgery, New York, NY, USA.

Background: The primary objective of the present study was to investigate how preoperative imaging modalities including 3D computed tomography (CT) scans with preoperative planning software affect implant choice for shoulder arthroplasty.

Methods: X-ray, uncorrected 2D CT scans, and 3D CT scans from 21 patients undergoing primary arthroplasty were reviewed by five shoulder surgeons. Each surgeon measured glenoid version, inclination and humeral head subluxation, and then selected an anatomic or reverse shoulder arthroplasty implant based only on these imaging parameters. Each surgeon virtually positioned the implant. Agreement between surgeons and changes in plan for individual surgeons between imaging modalities were assessed.

Results: Average measurements of native version, inclination, and subluxation were similar across all imaging modalities with very good interobserver reliability. Overall, there was a high rate of variability in choice of implant depending on imaging modality. Agreement on implant selection between surgeons improved from 68.6% using x-ray to 80.0% with 3D CT. Introducing age added significant variability, reducing agreement on implant choice to 61.0% with 3D CT.

Conclusions: The use of preoperative 3D planning changes implant choice in nearly one-third of cases compared to plain radiographs and improves surgeon agreement on implant choice compared to x-ray and 2D CT. III.
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http://dx.doi.org/10.1177/1758573221989306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9284305PMC
August 2022

A Comparison of Central Screw versus Post for Glenoid Baseplate Fixation in Reverse Shoulder Arthroplasty Using a Lateralized Glenoid Design.

J Clin Med 2022 Jun 29;11(13). Epub 2022 Jun 29.

Oregon Shoulder Institute, Medford, OR 97504, USA.

The purpose of this study was to compare the short-term clinical and radiographic outcomes of a lateralized glenoid construct with either a central screw or post. A multicenter retrospective study was conducted of reverse shoulder arthroplasties (RSAs) with minimum 2-year clinical followup. All RSAs implanted had a 135° neck shaft angle (NSA) and a modular circular baseplate. The patients were divided into two cohorts based on the type of central fixation for their glenoid baseplates (central post (CP) vs. central screw (CS)). The clinical outcomes, rates of revisions, and available radiographs were evaluated. In total, 212 patients met the study criteria. Postoperatively, both groups improved over their preoperative baseline. There were no significant differences between the cohorts in any PROs at 2 years postoperatively. No findings of gross loosening were identified in either cohort. Implant survival was 98.6% at 2 years. When using a lateralized glenoid implant with a 135° NSA inlay humeral component, both central post and central screw baseplate fixation provide good clinical outcomes, survivorship, and improvements in ROM at 2 years. There is no difference in loosening or revision rates between the types of baseplate fixation at a minimum of 2 years postoperatively.
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http://dx.doi.org/10.3390/jcm11133763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9267675PMC
June 2022

Short-term clinical and radiographic outcomes of a hybrid all-polyethylene glenoid based on preoperative glenoid morphology.

J Shoulder Elbow Surg 2022 Jun 21. Epub 2022 Jun 21.

Southern Oregon Orthopedics, Medford, OR, USA. Electronic address:

Background: The primary purpose of this study was to compare two-year anatomic total shoulder (TSA) functional and radiographic outcomes between Walch A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique.

Methods: A multicenter retrospective review was performed of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient reported outcomes (PROs) and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology, preoperative and postoperative glenoid version, glenoid inclination, posterior humeral head subluxation, and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications.

Results: 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (p < 0.001), range of motion (forward elevation, external rotation at 0, ER at 90, internal rotation spinal level, and internal rotation at 90; p < 0.001), and strength measures (Constant, external rotation, and modified belly press; p < 0.001). There were no clinically meaningful differences in functional outcome or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed cementing the central peg had the worst radiographic outcomes based on Lazarus scoring.

Conclusion: Patients undergoing TSA with a hybrid in-line pegged glenoid do well at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.
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http://dx.doi.org/10.1016/j.jse.2022.05.016DOI Listing
June 2022

Perianchor Cyst Formation Is Similar Between All-Suture and Conventional Suture Anchors Used for Arthroscopic Rotator Cuff Repair in the Same Shoulder.

Arthrosc Sports Med Rehabil 2022 Jun 1;4(3):e949-e955. Epub 2022 Mar 1.

Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, U.S.A.

Purpose: The purpose of this study was to compare perianchor cyst formation between soft and hard suture anchors placed in the same patient 1 year after arthroscopic rotator cuff repair (ARCR).

Methods: This study reviewed patients who underwent primary ARCR using a "hybrid" technique using at least one soft anchor (FiberTak, Arthrex, Naples, FL) and one hard anchor (SwiveLock) placed in the same shoulder between January 1, 2018 and December 31, 2018. Magnetic resonance imaging was obtained at minimum 1-year postoperative to assess cyst formation (perianchor fluid signal) and rotator cuff healing. Range of motion (ROM) and patient-reported outcome measures (PROMs) were evaluated at baseline and 1-year follow up. PROMs included visual analog scale pain score, Simple Shoulder Test score, American Shoulder and Elbow Surgeon (ASES) score.

Results: Nineteen patients with a combined 45 hard and 26 soft suture anchors were available for follow-up at a mean of 20 months postoperatively. There was a higher proportion of grade 1 fluid signal changes in the hard anchor group compared to the soft group (62.2% to 7.7; < .001); however, there was no difference in the incidence of cyst formation (grade 2 or 3 changes) between groups (13.3% vs 3.8%;  = .251). There was also no difference in the rate of cyst formation between biocomposite and polyether-ether-ketone-type hard anchors (18.2% vs 0%;  = .113) or between anchors placed at the greater and lesser tuberosities (10.2% vs 5.3%,  = .519).

Conclusion: Hard suture anchors showed increased fluid signal compared to soft suture anchors at short-term follow-up after ARCR, but there was no difference in cyst formation between anchor types.
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http://dx.doi.org/10.1016/j.asmr.2022.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9210368PMC
June 2022

Venous Thromboembolic Events are Exceedingly Rare in Spinal Fusion for Adolescent Idiopathic Scoliosis.

Clin Spine Surg 2022 Jun 13. Epub 2022 Jun 13.

Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA.

Study Design: Review of health care record database and determination of population statistics.

Objective: The purpose of this study was to quantify the incidence of clinically significant venous thromboembolic (VTE) events in patients undergoing spinal fusion surgery for adolescent idiopathic scoliosis (AIS) and to identify risk factors for VTE.

Summary Of Background Data: VTE is a serious complication that can cause disability and even death following surgery. Incidence of VTE following AIS surgery has not been well studied; the use of a national database allows the assessment of rare, yet important complications.

Materials And Methods: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2020. Patient records were cross-referenced for documented VTEs within 30 and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors for correlation with VTE events.

Results: Thirty-eight of 11,775 (0.323%) patients undergoing surgery for AIS developed a VTE complication within 90 postoperative days. Hypercoagulability [odds ratio (OR)=13.50, P<0.0001], spinal fusion involving 13+ vertebral levels (OR=2.61, P<0.0001), obesity (OR=1.30, P<0.005), and older (15-18 y) compared with younger adolescence (10-14 y) (OR=2.12, P<0.0001) were associated with VTE. Seven of 38 (18.4%) patients with a diagnosed thrombophilia experienced VTE.

Conclusions: The incidence of clinically significant VTEs in pediatric patients following spinal fusion surgery for AIS is low with an incidence of 0.323%. Postoperative chemoprophylaxis in the general pediatric population is not indicated. Patients with obesity, those undergoing spinal fusion of 13 or more vertebrae, and adolescents 15-18 years old were found to have higher but still small risk of VTE following surgery. Further prospective studies are needed to validate the risk profile of patients with hypercoagulability and establish clinical guidelines for use of postoperative chemoprophylaxis in this cohort.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001353DOI Listing
June 2022

Use of Supplemental Home Oxygen is Associated With Early Postoperative Complications Following Total Knee Arthroplasty.

J Arthroplasty 2022 Jun 1. Epub 2022 Jun 1.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia.

Background: The objective of this study is to evaluate preoperative supplemental home oxygen use as a potential risk factor for both medical and surgical complications following primary elective total knee arthroplasty (TKA) in patients who have respiratory disease (RD).

Methods: Patients with a diagnosis of RD who underwent elective TKA from 2010 to 2020 were identified using a national database. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated for RD patients who used supplemental home oxygen and those who did not. Additionally, reimbursements and lengths of stay were determined. Both cohorts were then compared to matched cohorts who did not have RD using logistic regression analyses.

Results: A total of 41,418 patients who underwent TKA with RD on home oxygen and 138,635 patients who had RD without home oxygen use were compared with matched cohorts. The RD cohort with home oxygen use had a significantly higher incidence of periprosthetic joint infection (5.78% versus 2.69%, odds ratio [OR] 1.42, P < .0001), pneumonia (3.95% versus 0.69%, OR 4.44, P < .0001), venous thromboembolism (3.17% versus 2.10%, OR 1.12, P = .007), and periprosthetic fracture (0.82% versus 0.34%, OR 1.72, P < .0001) compared to the matched control cohort. Additionally, the RD with home oxygen cohort had a significantly higher incidence of periprosthetic joint infection (5.78% versus 3.77%, OR 1.15, P < .0001), pneumonia (3.95% versus 1.63%, OR 1.99, P < .0001), and several other medical complications compared to RD patients without home oxygen use.

Conclusion: Preoperative supplemental home oxygen use is associated with significantly increased risk of postoperative surgical and medical complications following elective TKA. This finding can help guide risk assessment and the informed consent process prior to surgery.
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http://dx.doi.org/10.1016/j.arth.2022.05.044DOI Listing
June 2022

Preoperative Risk Factors for Primary Metatarsophalangeal Arthroplasty Revision to MTP Arthrodesis for Hallux Rigidus.

Foot Ankle Int 2022 Jun 1:10711007221094837. Epub 2022 Jun 1.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.

Background: Revision or conversion to arthrodesis following metatarsophalangeal (MTP) joint arthroplasty are salvage procedures to manage complications of MTP joint arthroplasty. The purpose of this study is to use a national administrative database to characterize nationwide trends of patients undergoing hallux MTP arthrodesis vs arthroplasty for hallux rigidus. Additionally, the authors sought to evaluate demographic trends and evaluate influence of patient-related risk factors in those undergoing MTP arthroplasty revision to arthrodesis.

Methods: Patients who underwent MTP arthroplasty for diagnosis of hallux rigidus from 2010 to 2019 were identified in the Mariner subset of the PearlDiver database. Patients were included if they had undergone MTP arthroplasty for the diagnosis of hallux rigidus. Notably, the database lacks resolution about critical features of the arthroplasty design and materials. The revision cohort encompassed patients who underwent subsequent ipsilateral MTP arthrodesis or arthroplasty within 2 years of index arthroplasty procedure. Demographic characteristics and medical comorbidities were examined as potential patient-related risk factors for arthroplasty revision or revision to fusion. Univariate analyses were performed to analyze differences in patient demographics, comorbidities, and risk factors. A multivariate regression analysis was subsequently conducted to control for confounding variables.

Results: 2750 patients underwent primary MTP arthroplasty for diagnosis of hallux rigidus. Of these, 44 (1.6%) underwent revision arthroplasty and 188 patients (6.8%) were revised to arthrodesis within the first 2 years after the index procedure. Multivariate regression analysis indicates that obesity (odds ratio [OR] 1.48, 95% CI 1.05-2.09), depression (OR 1.59, 95% CI 1.15-2.20), and steroid use (OR 2.94, 95% CI 1.30-6.65) were associated with a statistically significant increase in revision to arthrodesis from primary arthroplasty.

Conclusion: Revision arthrodesis following primary MTP arthroplasty for hallux rigidus within 2 years was found to be a relatively common occurrence in this national insurance database study. Risk factors for revision arthroplasty to arthrodesis within 2 years of primary arthroplasty include obesity, depression, and steroid use.

Level Of Evidence: Level III, case-control study.
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http://dx.doi.org/10.1177/10711007221094837DOI Listing
June 2022

A Radiographic Analysis of Proximal Humeral Anatomy in Patients with Primary Glenohumeral Arthritis and Implications for Press-Fit Stem Length.

J Clin Med 2022 May 19;11(10). Epub 2022 May 19.

Oregon Shoulder Institute, 2780 E. Barnett Road, Suite 200, Medford, OR 97504, USA.

While short stems in total shoulder arthroplasty (TSA) preserve bone stock and facilitate revision surgery, they have been associated with higher rates of malalignment and loosening in some cases compared to standard length stems. The purpose of this study was to analyze the intramedullary canal in progressive increments distal to the greater tuberosity to provide anatomic information about the optimal length of press-fit short stems for alignment and stability in TSA. We hypothesized that the humeral canal diameter will remain variable for the first 50 to 75 mm distal to the greater tuberosity and will become consistent thereafter. A retrospective review of 99 consecutive patients undergoing TSA with CT scans was performed. Intramedullary anterior-posterior (AP) and medial-lateral (ML) width as well as diameter were analyzed on two-dimensional computed tomography following multiplanar reconstruction. Measurements were taken at consistent distances distal to the greater tuberosity (GT). The transition point was measured at the proximal level of the humerus where endosteal borders of the medial and lateral cortices became parallel. The mean transition point was 73 mm from the GT (range: 53 to 109 mm). ML and AP widths became consistent 80 mm distal to the GT. IM diameter became consistent after 90 mm distal to the GT and a stem length of 90 mm extended past the transition point in 91.9% of cases. In TSA, a humeral stem length of 90 mm is required to predictably reach points at which the humeral canal becomes cylindrical and consistent in diameter. This information may aid data-driven decisions on humeral stem length during press-fit fixation, assuring consistency of alignment and implant stability, while maintaining ease of revision associated with a short stem implant. Level of evidence: III.
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http://dx.doi.org/10.3390/jcm11102867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9148163PMC
May 2022

Disagreement in Pass Rates Between Strength and Performance Tests in Patients Recovering From Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2022 07 23;50(8):2111-2118. Epub 2022 May 23.

Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.

Background: Performance on strength and functional tests is often used to guide postoperative rehabilitation progress and return to activity decisions after anterior cruciate ligament reconstruction (ACLR). Clinicians may have difficulty in determining which criteria to follow if there is disagreement in performance outcomes among the tests.

Purpose/hypothesis: The purpose of this study was to compare pass rates between strength tests and single-leg hop (SLHOP) tests among men and women and between patients with lower and higher preinjury activity levels recovering from ACLR. We hypothesized that pass rates would be nonuniformly distributed among test types, sex, and activity level and that more participants would pass hop tests than strength tests.

Design: Cross-sectional study; Level of evidence, 3.

Methods: A total of 299 participants (146 men; 153 women)-at a mean of 6.8 ± 1.4 months after primary, unilateral, and uncomplicated ACLR (mean age, 23 ± 9.7 years; mean height, 172 ± 10.5 cm; mean mass, 75.8 ± 18.4 kg)-completed testing. Quadri.tif strength was evaluated using peak torque during isokinetic knee extension at 90 deg/s and 180 deg/s. Jump distance during the SLHOP and triple hop tests was measured (in cm). Strength and hop test measures were evaluated based on the limb symmetry index ((LSI) = (ACLR / contralateral side) × 100). We operationally defined "pass" as 90% on the LSI.

Results: Pass rates were nonuniformly distributed between isokinetic knee extension at 90 deg/s and the SLHOP test ( = 18.64; < .001). Disagreements between isokinetic testing at 90 deg/s and the SLHOP test occurred in 36.5% (109/299) of the participants. Among those who failed strength testing and passed hop testing, a greater portion reported higher activity levels before their injury ( = 6.90; = .01); however, there was no difference in pass rates between men and women. Similar patterns of disagreement were observed between all strength test and hop test outcomes.

Conclusion: ACLR patients with higher activity levels may be more likely to pass hop testing despite failing quadri.tif strength testing. This may be an indicator of movement compensations to achieve jump symmetry in the presence of quadri.tif weakness.
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http://dx.doi.org/10.1177/03635465221097712DOI Listing
July 2022

The Timing of Preoperative Urinary Tract Infection Influences the Risk of Prosthetic Joint Infection Following Primary Total Hip and Knee Arthroplasty.

J Arthroplasty 2022 May 19. Epub 2022 May 19.

University of Virginia Health System, UVA Orthopaedic Center Ivy Road, Charlottesville, Virginia.

Background: The importance of preoperative urinary tract infection (UTI) in total hip and knee arthroplasty (THA and TKA) is controversial. The purpose of this study was to investigate the timing of preoperative UTI diagnosis and association with prosthetic joint infection (PJI) and determine if antibiotics impact this risk.

Methods: A national database was used to analyze patients undergoing THA and TKA diagnosed with a preoperative UTI. Timing of diagnosis was categorized by 1-week intervals prior to surgery. Matched cohorts without UTI were collected, and PJI rates within 2 years of surgery were compared. Patients who received antibiotic prescriptions were identified and compared to no prescription.

Results: Preoperative UTI within 1 week of TKA was associated with higher rates of PJI (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.26-1.43, P < .001). Preoperative UTI within 1 week of THA (OR 1.56, 95% CI 1.44-1.68, P < .001) and between 1-2 weeks prior to THA (OR 1.12, 95% CI 1.02-1.22, P = .022) was associated with significantly higher rates of PJI. UTI diagnosis at any other time interval did not reach statistical significance. Antibiotic prescription was not associated with lower rates of PJI.

Conclusion: Patients with preoperative UTI within 1 week of TKA or within 2 weeks of THA have an increased risk of postoperative PJI. Antibiotics do not appear to mitigate risk.

Level Of Evidence: Level III; Retrospective, database comparison.
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http://dx.doi.org/10.1016/j.arth.2022.05.034DOI Listing
May 2022

The influence of preoperative rotator cuff cross-sectional area and strength on postoperative outcomes in reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2022 May 10. Epub 2022 May 10.

Oregon Shoulder Institute, Medford, OR, USA. Electronic address:

Background: Although preoperative function and range of motion (ROM) are determinants of postoperative outcome following reverse shoulder arthroplasty (RSA), there is limited data on the influence of preoperative rotator cuff status. The purpose of this study was to evaluate the relationship between preoperative rotator cuff physiologic cross-sectional area (PCSA) and strength on postoperative RSA outcome.

Methods: A retrospective review was conducted on 53 primary RSAs from a multicenter database performed between 2015 and 2019 using a 135° humeral neck-shaft angle. Preoperative magnetic resonance imaging and computed tomographic scans were used to assess the PCSA of the subscapularis, supraspinatus, infraspinatus, and teres minor. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, ROM, and strength were measured preoperatively and at a minimum of 2 years postoperatively. Correlation coefficients were used to determine the relationship between variables.

Results: There were no significant correlations between preoperative PCSA of any rotator cuff muscles and postoperative ASES scores. Preoperative subscapularis PCSA positively correlated with change in belly press (BP) strength following RSA (⍴ = 0.37, P = .006). Preoperative abduction strength was significantly correlated with postoperative abduction strength (⍴ = 0.297, P = .006). Preoperative external rotation (ER) strength was significantly correlated with postoperative ER (⍴ = 0.378, P = .005) and abduction (⍴ = 0.304; P = .032) strength. Preoperative BP strength negatively correlated with postoperative ASES (⍴ = -0.283, P = .042) but positively correlated with postoperative BP (⍴ = 0.411, P = .001) and abduction (⍴ = 0.367, P = .009) strength.

Conclusion: With the use of a 135° humeral implant, there is limited correlation between preoperative PCSA and postoperative outcomes 2 years following RSA; the only significant correlation was between preoperative subscapularis PCSA and postoperative BP strength. Preoperative strength is positively correlated with postoperative strength but not ROM or ASES scores.
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http://dx.doi.org/10.1016/j.jse.2022.04.003DOI Listing
May 2022

Estimating the Impact of Postamputation Pain.

Ann Plast Surg 2022 05;88(5):533-537

From the Department of Plastic Surgery.

Background: Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation.

Methods: Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities.

Results: There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain.

Conclusions: Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.
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http://dx.doi.org/10.1097/SAP.0000000000003009DOI Listing
May 2022

Predicting Anterior Cruciate Ligament Reinjury From Return-to-Activity Assessments at 6 Months Postsurgery: A Prospective Cohort Study.

J Athl Train 2022 Apr;57(4):325-333

University of Virginia, Charlottesville.

Context: Return-to-activity (RTA) assessments are commonly administered after anterior cruciate ligament reconstruction (ACLR) to manage the patient's postoperative progressions back to activity. To date, few data are available on the clinical utility of these assessments to predict patient outcomes such as secondary anterior cruciate ligament (ACL) injury once the athlete has returned to activity.

Objective: To identify the measures of patient function at 6 months post-ACLR that best predict RTA and second ACL injury at a minimum of 2 years after ACLR.

Design: Prospective cohort study.

Setting: Laboratory.

Patients Or Other Participants: A total of 234 patients with primary, unilateral ACLR completed functional assessments at approximately 6 months post-ACLR. Of these, 192 (82.1%) completed follow-up at ≥2 years post-ACLR.

Main Outcome Measure(s): The 6-month functional assessments consisted of patient-reported outcomes, isokinetic knee-flexor and -extensor strength, and single-legged hopping. We collected RTA and secondary ACL injury data at ≥2 years after ACLR.

Results: Of the patients who were able to RTA (n = 155), 44 (28.4%) had a subsequent ACL injury, 24 (15.5%) to the ipsilateral graft ACL and 20 (12.9%) to the contralateral ACL. A greater proportion of females had a secondary injury to the contralateral ACL (15/24, 62.5%), whereas a greater proportion of males reinjured the ipsilateral ACL graft (15/20, 75.0%; P = .017). Greater knee-extension symmetry at 6 months increased the probability of reinjury (B = 0.016, P = .048). Among patients with RTA at <8 months, every 1% increase in quadriceps strength symmetry at 6 months increased the risk of reinjury by 2.1% (B = 0.021, P = .05). Among patients with RTA at >8 months, every month that RTA was delayed reduced the risk of reinjury by 28.4% (B = -0.284, P = .042). Descriptive statistics of patient function stratified between the early and delayed RTA groups can be found in the Supplemental Table (available online at http://dx.doi.org/10.4085/1062-6050-0407.20.S1).

Conclusions: Patients with more symmetric quadriceps strength at 6 months post-ACLR were more likely to experience another ACL rupture, especially those who returned to sport at <8 months after the index surgery. Clinicians should be cognizant that returning high-functioning patients to activity at <8 months post-ACLR may place them at an increased risk for reinjury.
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http://dx.doi.org/10.4085/1062-6050-0407.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9020598PMC
April 2022

Outcomes Following Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients on Hemodialysis.

J Bone Joint Surg Am 2022 04;104(Suppl 2):90-94

Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia.

Background: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients on hemodialysis (HD) are at increased risk for complications after THA for osteoarthritis, however there is limited information on outcomes of THA for ONFH in patients on HD. With increasing prevalence of chronic kidney disease (CKD) requiring HD, studies are needed to characterize the risk of complications in these patients. Therefore, the purpose of this study was to evaluate HD as a potential risk factor for complication after THA in patients with ONFH on HD.

Methods: Patients on HD with ONFH who underwent THA with at least 2 years of follow-up were identified using a combination of ICD-9 and CPT codes in a national insurance database. A 10:1 matched control cohort of patients with ONFH not on HD was created for comparison. A logistic regression analysis was used to evaluate rates of death, hospital readmission, emergency room (ER) visit, infection, revision, and dislocation between cohorts. Differences in hospital charges, reimbursement, and length of stay between the two groups were also assessed.

Results: One thousand one hundred thirty-seven patients on HD who underwent THA for ONFH were compared to a matched control cohort of 11,182 non-HD patients who underwent THA for ONFH. Patients on HD experienced higher rates of death (HD 4.1%, non-HD 0.9%; odds ratio [OR] 3.35, p < 0.01), hospital readmission (HD 16.1%, non-HD 5.9%; OR 2.69, p < 0.01) and ER visit (HD 10.4%, non-HD 7.4% OR 1.5, p < 0.01). Hemodialysis was not associated with higher risk of infection, revision, or dislocation, but was associated with significantly higher charges (p < 0.01), reimbursement (p < 0.01), and hospital length of stay (p < 0.01).

Conclusions: While patients on HD do not have increased risk of implant-related complications, they are at increased risk of developing medical complications following THA for ONFH and subsequently may require more resources. Orthopedic surgeons and nephrologists should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

Level Of Evidence: Therapeutic Level III.
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http://dx.doi.org/10.2106/JBJS.20.00352DOI Listing
April 2022

Outcomes following Total Hip Arthroplasty for Femoral Head Osteonecrosis in Patients with History of Solid Organ Transplant.

J Bone Joint Surg Am 2022 04;104(Suppl 2):76-83

University of Virginia Health System, Department of Orthopaedic Surgery, Charlottesville, Virginia.

Background: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients with solid organ transplant (SOT) are at increased risk of postoperative complications after THA for osteoarthritis. The objective of the present study is to evaluate SOT as a potential risk factor for complication after THA for ONFH.

Methods: This is a retrospective study that identified patients with SOT who underwent THA for ONFH from 2005 to 2014 in a national insurance database and compared them to 5:1 matched controls without transplant. Subgroup analyses of patients with renal transplant (RT) and those with non-RT were also analyzed. A logistic regression analysis was used to compare rates of mortality, hospital readmission, emergency room (ER) visits, infection, revision, and dislocation while controlling for confounders. Differences in hospital charges, reimbursement, and length of stay (LOS) were also compared.

Results: 996 patients with SOT who underwent THA were identified and compared to 4,980 controls. SOT patients experienced no increased risk of early postoperative complications compared to controls. Solid organ transplant was associated with higher resource utilization and LOS. Renal transplant patients were found to have significantly higher risk of hospital readmission at 30 days (odds ratio [OR] 1.77; p = 0.001) and 90 days (OR 1.62; p < 0.001) and hospital LOS (p < 0.001), but had lower risk of infection (OR 0.65; p = 0.030). Non-RT patients had higher rate of ER visits at 30 days (OR 2.26; p = 0.004) but lower rates of all-cause revision (OR 0.22; p = 0.043).

Conclusions: Patients with history of SOT undergoing THA for ONFH utilize more hospital resources with longer LOS and greater risk of readmission but are not necessarily at an increased risk of early postoperative complications.
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http://dx.doi.org/10.2106/JBJS.20.00397DOI Listing
April 2022

Risk Factors, Management, and Prognosis of Brachial Plexopathy Following Reverse Total Shoulder Arthroplasty.

Orthop Clin North Am 2022 Apr 5;53(2):215-221. Epub 2022 Mar 5.

University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903, USA. Electronic address:

Brachial plexus injuries can have a significant impact on patient outcomes following RTSA by slowing the overall recovery and return of function. Risk factors for brachial plexopathy include traction injury related to arm positioning and exposure during the procedure, direct nerve injury from surgical dissection, and compression injury from retractor placement. Risk of nerve injury can be minimized by limiting the time spent with the arm extended and externally rotated and avoiding excessive traction on the arm during humeral preparation and implant insertion. Prompt identification of postoperative brachial plexopathy is important to optimize the recovery of function.
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http://dx.doi.org/10.1016/j.ocl.2021.11.007DOI Listing
April 2022

Flexible Versus Rigid Reaming Systems for Independent Femoral Tunnel Reaming During ACL Reconstruction: Minimum 2-Year Clinical Outcomes.

Orthop J Sports Med 2022 Mar 16;10(3):23259671221083568. Epub 2022 Mar 16.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.

Background: Radiographic and cadaveric studies have suggested that anatomic anterior cruciate ligament reconstruction (ACLR) femoral tunnel drilling with the use of a flexible reaming system through an anteromedial portal (AM-FR) may result in a different graft and femoral tunnel position compared with using a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR). No prior studies have directly compared clinical outcomes between the use of these 2 techniques for femoral tunnel creation during ACLR.

Purpose: To compare revision rates at a minimum of 2 years postoperatively for patients who underwent ACLR with AM-FR versus AAM-RR. The secondary objectives were to compare functional testing and patient-reported outcomes between the cohorts.

Study Design: Cohort study; Level of evidence, 3.

Methods: Included were consecutive patients at a single academic institution between 2013 and 2018 who underwent primary ACLR without additional ligamentous reconstruction. Patients were separated into 2 groups based on the type of anatomic femoral tunnel drilling: AM-FR or AAM-RR. Graft failure, determined by revision ACLR, was assessed with a minimum 2 years of postoperative follow-up. The authors also compared patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and functional performance testing performed at 6 months postoperatively.

Results: A total of 284 (AAM-RR, 232; AM-FR, 52) patients were included. The mean follow-up time was 3.7 ± 1.5 years, with a minimum 2-year follow-up rate of 90%. There was no significant difference in the rate of revision ACLR between the AAM-RR and AM-FR groups (10.8% vs 9.6%, respectively; = .806). At 6 months postoperatively, there were no significant between-group differences in peak knee extension strength, peak knee flexion strength, limb symmetry indices, or hop testing, as well as no significant differences in IKDC (AAM-RR, 81.1; AM-FR, 78.9; = .269) or KOOS (AAM-RR, 89.0; AM-FR, 86.7; = .104).

Conclusion: In this limited study, independent femoral tunnel drilling for ACLR using rigid or flexible reaming systems resulted in comparable rates of revision ACLR at a minimum of 2 years postoperatively, with no significant differences in strength assessments or patient-reported outcomes at 6 months postoperatively.
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http://dx.doi.org/10.1177/23259671221083568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8935574PMC
March 2022

Initial and 1-Year Radiographic Comparison of Reverse Total Shoulder Arthroplasty With a Short Versus Standard Length Stem.

J Am Acad Orthop Surg 2022 Jul 15;30(14):e968-e978. Epub 2022 Mar 15.

From the Department of Orthopaedic Surgery, Sports Medicine and Shoulder, Rothman Orthopaedic Institute, New York, NY (Erickson), Southern Oregon Orthopedics, Medford, OR (Denard and Griffin), Jordan-Young Institute, Virginia Beach, VA, (Griffin) Cleveland Shoulder Institute, Beachwood, OH (Gobezie), University of Arizona College of Medicine-Phoenix, Phoenix, AZ (Lederman), and University of Virginia, Charlottesville, VA (Werner).

Introduction: In an effort to preserve bone, humeral stems in reverse total shoulder arthroplasty (RTSA) have gradually decreased in length. The purpose of this study was to compare the immediate postoperative radiographic appearance of short-length with standard-length RTSA stems.

Methods: Patients who underwent RTSA using a press-fit standard-length or short-length humeral implant with a consistent geometry (Univers Revers or Revers Apex) were evaluated in a multicenter retrospective review. Initial postoperative radiographs were used to assess initial alignment and filling ratios. In addition, radiographs were evaluated for early signs of stress shielding and/or loosening. Clinical outcome scores and range of motion were also evaluated.

Results: Overall, 137 short-length stems and 139 standard-length stems were analyzed. Initial radiographs demonstrated a significantly higher percentage of stems placed in neutral alignment in the short-stem group (95.6% vs 89.2%, P = 0.045). Similar metaphyseal filling ratios were seen between groups, but a significantly higher diaphyseal filling ratio was observed in the short-stem group (57% vs 34%, P < 0.001). Less calcar osteolysis (2.2% vs 12.9%; P = 0.001) and fewer overall number of radiographic changes (tuberosity resorption, lucencies, and subsidence) (0.7% vs 5.0%; P = 0.033) were seen with short stems compared with the standard-length stems.

Conclusion: RTSA with a short-stem humeral implant demonstrates excellent radiographic outcomes, including low rates of loosening and subsidence at 1 year, with less early calcar osteolysis compared with a standard-length stem.

Level Of Evidence: III (Case-control).
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http://dx.doi.org/10.5435/JAAOS-D-21-01032DOI Listing
July 2022

Patient age at time of reverse shoulder arthroplasty remains stable over time: a 7.5-year trend evaluation.

Eur J Orthop Surg Traumatol 2022 Mar 10. Epub 2022 Mar 10.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.

Purpose: There is a common belief among some shoulder surgeons that the increased utilization of reverse shoulder arthroplasty (RSA) is driven by the operation being performed in younger patients. The primary purpose of this study was to evaluate the change in patient age at the time of primary RSA in the USA.

Methods: All patients undergoing primary RSA (January 2011-June 2018) were identified in the Mariner database. The mean age at the time of primary RSA was evaluated for each patient and assessed in 6-month intervals. A longitudinal comparison over time was performed for all patients.

Results: A total of 56,141 primary RSA were evaluated, with the mean age increasing from 69 in the 2011 to 71 in 2018 (p < 0.001). The largest increase in RSA utilization occurred in patients > 70 (1092 in 2011 to 3499 in 2018), with patients < 50 years demonstrating the slowest growth (13 in 2011 to 65 in 2018). However, when evaluated by percentage increase from 2011 to 2018, RSA volumes for patients < 60 have increased 390% compared to 220% for those > 70 years (p < 0.001).

Conclusion: RSA continues to be performed at a similar mean age despite expanded indications and surgeon comfort. However, patients < 60 years have had a greater increase in utilization compared to patients > 70 years. The volumetric growth of RSA has largely been driven by the older population, but younger patients have shown a higher percentage of growth, which may explain the generalized observation that RSA is performed in younger patients.

Level Of Evidence: Level III; Retrospective comparative study; Treatment study.
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http://dx.doi.org/10.1007/s00590-022-03227-wDOI Listing
March 2022

The Feasibility of Translaminar Screws in the Subaxial Cervical Spine: Computed Tomography and Cadaveric Validation.

Clin Orthop Surg 2022 Mar 15;14(1):105-111. Epub 2022 Feb 15.

Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.

Background: The use of translaminar screws may serve as a viable salvage method for complicated cases. To our understanding, the study of the feasibility of translaminar screw insertion in the actual entire subaxial cervical spine has not been carried out yet. The purpose of this study was to report the feasibility of translaminar screw insertion in the entire subaxial cervical spine.

Methods: Eighteen cadaveric spines were harvested from C3 to C7 and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were created to exclude any bony anomaly. Thirty anatomically intact segments were collected (C3, 2; C4, 3; C5, 3; C6, 8; and C7, 14), and randomly arranged. Twenty-one segments were physically separated at each vertebral level (group S), while 9 segments were not separated from the vertebral column and left in situ (group N-S). CT measurement of lamina thickness was done for both group S and group N-S, and manual measurement of various length and angle was done for group S only. Using the trajectory proposed by the previous studies, translaminar screws were placed at each level. Screw diameter was the same or 0.5 mm larger than the proposed diameter based on CT measurement. Post-insertion CT was performed. Cortical breakage was checked either visually or by CT.

Results: When 1° and 2° screws of the same size were used, medial cortex breakage was found 13% and 33% of the time, respectively. C7 was relatively safer than the other levels. With larger-sized screws, medial cortex breakage was found in 47% and 46% of 1° and 2° screws, respectively. There were no facet injuries due to the screws in group N-S.

Conclusions: Translaminar screw insertion in the subaxial cervical spine is feasible only when the lamina is thick enough to avoid any breakage that could lead to further complications. The authors do not recommend inserting translaminar screws in the subaxial cervical spine except in some salvage cases in the presence of a thick lamina.
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http://dx.doi.org/10.4055/cios21059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8858891PMC
March 2022

Why patients fail to achieve a Patient Acceptable Symptom State (PASS) after total shoulder arthroplasty?

JSES Int 2022 Jan 17;6(1):49-55. Epub 2021 Nov 17.

Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, OR, USA.

Background: The purpose of this study was to compare patient-reported outcomes (PROs) and range of motion (ROM) measurements between patients achieving and failing to achieve a Patient Acceptable Symptom State (PASS) after anatomic total shoulder arthroplasty (TSA) to determine which PRO questions and ROM measurements were the primary drivers of poor outcomes.

Methods: A retrospective review of a multicenter database identified 301 patients who had undergone primary TSA between 2015 and 2018 with ROM and PRO data recorded preoperatively and at a minimum of two years postoperatively. The primary outcome was the difference in active ROM between patients achieving and failing to achieve the PASS threshold for the American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. The secondary outcome was the difference in self-reported pain levels between those achieving and failing to achieve a PASS.

Results: Based on the ASES PASS threshold, 87% (261/301) of patients achieved a PASS after TSA, whereas 13% did not. Based on the SANE PASS threshold, 69% (208/301) of patients achieved a PASS after TSA, whereas 31% did not. Patients who failed to achieve a PASS after TSA were younger and had lower short form-12 mental health scores than those who did. There was a significant difference in pain between those who achieved and failed to achieve a PASS after TSA (ASES PASS current shoulder pain 16.5% vs. 95%,  < .001, SANE PASS current shoulder pain 13% vs. 58.1%,  < .001). Those failing to reach a PASS had significantly higher pain levels (ASES PASS Visual Analog Scale pain scores [4.2 vs. 0.4,  < .001] and SANE PASS Visual Analog Scale pain scores [2.0 vs. 0.4,  < .001]) and worse function in nearly all domains of the ASES and Western Ontario Osteoarthritis of the Shoulder index after surgery. There was little difference in ROM between those reaching and failing to reach a PASS (no difference in active external rotation with the arm adducted, active internal rotation at the nearest spinal level, or active internal rotation with the shoulder abducted to 90 degrees for ASES and SANE PASS).

Conclusion: There is variability in the percentage of patients who achieve a PASS after TSA, ranging from 69% to 87% depending on the PRO used to define the threshold. Patients who did not achieve a PASS after TSA were significantly more likely to have pain, whereas there were very few differences in ROM, indicating pain as the primary driver of failing to achieve a PASS. Setting realistic postoperative expectations for pain relief may be important for improving patient-reported results after TSA.
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http://dx.doi.org/10.1016/j.jseint.2021.09.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811410PMC
January 2022

Reverse total shoulder arthroplasty for patients with preserved active elevation and moderate-to-severe pain: a matched cohort study.

JSES Int 2022 Jan 19;6(1):1-6. Epub 2021 Nov 19.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.

Background: Patients undergoing reverse total shoulder arthroplasty (RTSA) predictably report reduced pain and improved function postoperatively. However, it is not known if patients with differing preoperative active motion achieve the same benefit after surgery. The purpose of the present study is to evaluate patient-reported outcomes (PROs), range of motion (ROM), and satisfaction after RTSA in patients with moderate-to-severe pain with preserved active preoperative ROM compared with matched controls with restricted preoperative active ROM.

Methods: A multicenter shoulder arthroplasty registry was utilized to identify patients with at least two-year clinical follow-up after RTSA with a 135° implant. The study cohort with preserved motion included patients with greater than one standard deviation above the overall mean for preoperative forward elevation (FE) (140°) as well as a preoperative visual analog pain scale (VAS) ≥ 5.0. The control cohort with more restricted motion had preoperative FE of less than 140° and also with preoperative VAS ≥5.0. The control patients were matched 2:1 to study patients by age (±2 years), sex, and preoperative VAS (±1.5). Outcomes measured were as follows: PROs, ROM, strength, and strength and satisfaction.

Results: Twenty-seven patients were identified that comprised the preserved preoperative FE study cohort; 54 patients were included in the restricted elevation cohort as controls. The groups were similar at baseline for demographics, surgical diagnoses, and most PROs, other than the Constant-Murley, which was higher in the preserved motion cohort. At two years postoperatively, both cohorts demonstrated similar PROs, strength, and ROM (other than internal rotation with the arm abducted 90 degrees) and had a similar number of patients who rated the RTSA as meeting or exceeding their expectations. The change in ROM from preoperatively was significantly different with the restricted cohort, achieving a larger increase in forward flexion (51 ± 26° vs. -13 ± 35°,  < .001).

Conclusion: Patients indicated for RTSA with preserved preoperative FE and moderate pain achieve similar final ROM, pain reduction, increases, and strength compared with patients who undergo RTSA with restricted preoperative FE. Despite losing on average 13 degrees of FE from preoperatively by two years postoperatively, patients with preserved preoperative FE are comparably satisfied with their outcome.
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http://dx.doi.org/10.1016/j.jseint.2021.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811383PMC
January 2022

Vascular Complications in Sports Surgery: Diagnosis and Management.

Sports Med Arthrosc Rev 2022 Mar;30(1):63-75

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA.

Orthopedic sports surgery of the knee and shoulder is generally considered to be safe and effective. Vascular complications can occur during or after arthroscopy of either joint. A thorough understanding of anatomy, particularly when placing portals in non-routine locations, is extremely important. Prompt recognition of any vascular complication is of significant importance. This review will discuss the potential vascular complications for both knee and shoulder sports surgery, review the relevant anatomy, and discuss the treatment and expected outcome of each.
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http://dx.doi.org/10.1097/JSA.0000000000000343DOI Listing
March 2022

Lesser Tuberosity Osteotomy Does Not Appear to Compromise Fixation or Function Compared With Peel in Short-Stem Anatomic Shoulder Arthroplasty.

Orthopedics 2022 May-Jun;45(3):151-155. Epub 2022 Feb 3.

Several methods are available for subscapularis management in total shoulder arthroplasty (TSA). The goal of this study was to compare radiographic and clinical outcomes of short-stem TSA stratified by subscapularis management technique. A multicenter trial was completed evaluating primary short-stem TSA performed with a subscapularis peel (n=80) or lesser tuberosity osteotomy (LTO) (n=59). The primary outcome measure was subscapularis function, as measured by internal rotation and strength at 1 year postoperatively. Secondary outcomes included patient-reported outcomes, radiographic changes, and implant loosening. Patients in the peel group obtained better active internal rotation by spinal level (=.004). No difference was seen between groups for internal rotation with 90° shoulder abduction (=.862) or belly press (=.903). Statistically significant improvements in functional outcomes were seen without clinical differences. Radiographic changes showed no difference in stem shift, subsidence, or at-risk loosening rate. Anterior subluxation of the humerus was observed among 2% of the LTO group vs 17% of the peel group (=.006). At short-term follow-up, those in the peel group appear to have a better final spinal level of internal rotation, whereas those in the LTO group have a significantly lower rate of anterior humeral subluxation. Both LTO and subscapularis peel appear safe for short-stem TSA, with no radiographic evidence of loosening. [. 2022;45(3):151-155.].
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http://dx.doi.org/10.3928/01477447-20220128-10DOI Listing
May 2022

COVID-19 as a Catalyst for Same-Day Discharge Total Shoulder Arthroplasty.

J Clin Med 2021 Dec 16;10(24). Epub 2021 Dec 16.

Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR 97504, USA.

The COVID-19 pandemic caused major disruptions to the healthcare system, but its impact on the transition to same-day discharge shoulder arthroplasty remains unexplored. This study assessed the effect of COVID-19 on length of stay (LOS), same-day discharge rates, and other markers of resource use after elective total shoulder arthroplasty. A total of 508 consecutive patients undergoing elective primary total shoulder arthroplasty between 2019 and 2021 were identified and divided into 2 cohorts: "pre-COVID" (March 2019-March 2020; = 263) and "post-COVID" (May 2020-March 2021; = 245). No elective shoulder arthroplasties were performed at our practice between 18 March and 11 May 2020. Outcome measures included LOS, same-day discharge, discharge location, and 90-day emergency department (ED) visits, readmissions and reoperations. There were no significant differences in baseline preoperative patient characteristics. Shoulder arthroplasty performed post-COVID was associated with a shorter LOS (12 vs. 16 h, = 0.017) and a higher rate of same-day discharge (87.3 vs. 79.1%, = 0.013). The rate of discharge to skilled nursing facilities was similarly low between the groups (1.9 vs. 2.0%, = 0.915). There was a significant reduction in the rate of 90-day ED visits post-COVID (7.4 vs. 13.3%, = 0.029), while there were no differences in 90-day reoperation (2.0 vs. 1.5%, = 0.745) or readmission rates (1.2 vs. 1.9%, = 0.724). The COVID-19 pandemic seems to have accelerated the shift towards shorter stays and more same-day discharge shoulder arthroplasties, while reducing unexpected acute health needs (e.g., ED visits) without adversely affecting readmission and reoperation rates.
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http://dx.doi.org/10.3390/jcm10245908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8709337PMC
December 2021

Reinjury Rates in Adolescent Patients 2 Years Following ACL Reconstruction.

J Pediatr Orthop 2022 Feb;42(2):90-95

Departments of Orthopaedics.

Background: Sports injuries have increased dramatically in the pediatric and adolescent population. Return-to-sport testing and criteria are increasingly utilized, however, the guidelines for return to play in adolescents are unclear. The purpose of this study was to compare strength and function at the time of the return-to-sport progression to those with and without a failed anterior cruciate ligament reconstruction (ACLR).

Methods: A total of 105 adolescent patients with primary ACLR were assessed at the time of return to sport. We identified graft failures/contralateral injury through medical records, clinic visits, or phone interviews at minimum 2 years of postsurgical follow-up. All patients completed bilateral isokinetic strength tests of the knee extensor/flexor groups and hop tests. Strength was expressed as torque-normalized-to-mass (Nm/kg), and limb-symmetry-index was expressed as a percentage of the uninvolved limb's strength. All patients completed outcome surveys. The χ2 analysis was used to compare failures between sexes and graft types. Independent sample t tests were used to compare knee extensor/flexor strength, symmetry, and hop test results between patients with and without secondary anterior cruciate ligament (ACL) injury. One-way analysis of variance was used to compare knee extensor/flexor strength and symmetry, hop test, and survey results between those (1) without secondary injury, (2) ACLR graft failure, and (3) contralateral ACL injury.

Results: A total of 100 of 105 patients (95.2%) were included with 4±1.2 years of follow-up, with 28 (28%) sustaining subsequent injury (12% graft, 16% contralateral). Patients with graft failure demonstrated (1) stronger quadriceps strength (2.00±0.46 Nm/kg) compared with those with contralateral ACL injury (1.58±0.35 Nm/kg, P=0.039) and patients that did not have a secondary injury (1.58±0.44 Nm/kg, P=0.007), (2) greater quadriceps strength symmetry (85.7±0.11.2%) compared with patients without secondary injury ACL (72.9±17.9%, P=0.046), (3) a greater proportion of hamstring grafts compared with those without reinjury (P=0.028).

Conclusions: Adolescent patients who sustained ACLR graft failure had greater and more symmetric quadriceps strength at the time of return to sport compared with patients with no secondary injury. Objective measures of quadriceps strength at the time of the return-to-sport progression may not solely identify individuals that have a secondary ACL injury.

Study Design: Level IV-retrospective cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000002031DOI Listing
February 2022

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications.

J Foot Ankle Surg 2021 Oct 22. Epub 2021 Oct 22.

Associate Professor, Department of Orthopaedics, University of Virginia Health Systems, Charlottesville, VA. Electronic address:

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.
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http://dx.doi.org/10.1053/j.jfas.2021.10.011DOI Listing
October 2021

The risk of early infection following intra-articular corticosteroid injection following shoulder arthroplasty.

Shoulder Elbow 2021 Oct 21;13(6):605-609. Epub 2020 May 21.

Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA.

Background: There is little literature examining the association of corticosteroid injections into shoulders with a pre-existing arthroplasty. The aim of the current study was to determine the risk of early infection following intra-articular corticosteroid injection into a pre-existing shoulder arthroplasty.

Methods: The PearlDiver database was retrospectively reviewed to identify patients with a pre-existing shoulder arthroplasty from 2007 to 2017. Patients with an ipsilateral shoulder corticosteroid injection in the postoperative period were identified. A control group of patients without an injection was matched 4:1 by age, gender, and postoperative timepoint. Periprosthetic infection within six months after the injection was then assessed and compared using a logistic regression analysis.

Results: Nine hundred and fifty-eight patients were identified who underwent a postoperative corticosteroid injection into a pre-existing shoulder arthroplasty and compared to 3832 control patients. After controlling for demographics, comorbidities, and procedure type, the rate of infection in patients who received a postoperative corticosteroid injection (1.77%) was significantly higher than control patients who did not receive an injection (0.91%) (OR 1.98 (95% CI 1.31-2.98), p = 0.0253).

Conclusions: There is a significant association between intra-articular shoulder corticosteroid injections in patients with pre-existing shoulder arthroplasties and prosthetic joint infection compared to matched controls without postoperative injections.

Study Design: Level III, retrospective cohort study.
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http://dx.doi.org/10.1177/1758573220925817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8600675PMC
October 2021

A biomechanical comparison of subscapularis tenotomy repair techniques for stemless shoulder arthroplasty.

J Shoulder Elbow Surg 2022 Apr 11;31(4):711-717. Epub 2021 Nov 11.

Arthrex, Naples, FL, USA.

Background: One of the leading challenges for surgeons shifting to stemless anatomic total shoulder arthroplasty (TSA) is subscapularis repair. In the available literature reporting outcomes after stemless TSA, subscapularis tenotomy with side-to-side repair is the most common technique despite some concerns regarding this technique in the biomechanical and clinical literature. Accordingly, this study investigated subscapularis tenotomy repair with stemless TSA with 2 primary objectives: (1) to evaluate the subscapularis tendon dimensions with reference to subscapularis tenotomy to determine the amount of tendon remaining for side-to-side repair after shoulder arthroplasty and (2) to biomechanically compare 2 methods of subscapularis tenotomy repair after stemless TSA-side-to-side repair and anchor-based repair.

Methods: We used 12 male shoulder specimens for this study. To address our first objective, measurements were made to calculate the dimensions of the subscapularis tendon at the superior, middle, and inferior levels to determine the amount of tendon remaining after tenotomy. These specimens were then divided into 2 groups (n = 6 in each group) to biomechanically compare subscapularis tenotomy repair with (1) traditional side-to-side repair and (2) anchor-based repair. The shoulders then underwent biomechanical testing with primary outcomes including load to failure and cyclic displacement.

Results: The mean subscapularis tendon width measured from the medial insertion at the lesser tuberosity to the muscle-tendon junction varied depending on the level: 19.5 mm superiorly (95% confidence interval [CI], 16.2-22.8 mm); 18.3 mm at the midportion (95% CI, 13.6-23.0 mm); and 13.1 mm inferiorly (95% CI, 9.1-17.1 mm). With a tenotomy made 1 cm medial to the lesser tuberosity insertion, a mean of 3.1 mm of tendon remained medially at the inferior subscapularis, with one-third of specimens having no tendon left medially at this level. On comparison of tenotomy repair techniques, the anchor-based technique had a 57% higher ultimate load to failure compared with the side-to-side repair (448 N vs. 249 N, P < .001). There were no significant differences in cyclic displacement (6.1 mm vs. 7.1 mm, P = .751) and construct stiffness (38.1 N/mm vs. 42.9 N/mm, P = .461) between techniques.

Conclusions: With traditional techniques for subscapularis tenotomy for anatomic TSA, there is very little tendon remaining inferiorly for side-to-side repair. When subscapularis tenotomy is performed for stemless TSA, a double-row anchor-based repair has a better time-zero ultimate load to failure compared with side-to-side repair.
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http://dx.doi.org/10.1016/j.jse.2021.10.017DOI Listing
April 2022
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