Publications by authors named "George S Athwal"

270 Publications

Medial elbow exposure: an anatomic comparison of 5 approaches.

J Shoulder Elbow Surg 2021 Mar 7;30(3):512-519. Epub 2020 Jul 7.

Hand and Upper Limb Centre, Western University, London, ON, Canada.

Purpose: Several surgical approaches to the medial elbow are described; however, it remains unclear which exposure provides the optimal view of relevant medial elbow structures. The purpose of this anatomic study was to determine the visible surface area of the coronoid process, distal humerus, and radial head through 5 approaches to the medial elbow.

Methods: Eight fresh-frozen cadaveric upper extremity specimens were dissected. Five surgical approaches were performed on each specimen. The Smith muscle-splitting approach to the ulnar collateral ligament was performed first (Smith), followed by the Hotchkiss medial "Over the top" approach (Hotchkiss), the extended medial elbow approach (EMEA), the flexor carpi ulnaris splitting approach (FCU-Split), and the Taylor and Scham approach (T&S). Bony visualization was determined using laser surface scanning (Artec Space Spider; Artec 3D). The scans were segmented using commercially available digital software (Geomagic Wrap; 3D Systems Corporation), and the surface area visualized was determined. A descriptive analysis of the joint areas visible using the medial collateral ligament (MCL) as a clinical landmark was performed.

Results: The EMEA visualized the highest proportion of the total elbow joint from the medial side showing 13.9 ± 6.0 cm, or 15% ± 4% of the joint. It also provided the best visualization of the coronoid (3.2 ± 1.7 cm of surface area, or 26% ± 9%) and distal humerus (9.9 ± 4.3 cm, or 15% ± 4%). The Hotchkiss approach was best at visualizing the radial head (0.8 ± 0.3 cm, or 7% ± 3%). The EMEA, Hotchkiss, and Smith approaches showed primarily the anterior bundle of the MCL, its insertion, and the regions anterior to it, whereas the FCU-Split showed the anterior bundle of the MCL and regions both anterior and posterior to it. The T&S showed primarily the areas posterior to the anterior bundle of the MCL; the anterior regions were not visible. The FCU-Split and the T&S allowed visualization of the posterior bundle of the MCL. The intraclass correlation coefficients (ICCs) for intraobserver reliability were 0.997, 0.992, and 0.974 for the test distal humerus, test coronoid, and test radial head, respectively. The ICCs for interobserver reliability were 0.915 for the test distal humerus, 0.66 for the coronoid, and 0.583 for the radial head.

Conclusion: The EMEA provides the most visualization of the coronoid and distal humerus, whereas the Hotchkiss showed the most radial head. However, these approaches mainly visualize structures anterior to the MCL. If exposure of structures posterior to the MCL is required, the FCU-Split and T&S approaches are more appropriate.
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http://dx.doi.org/10.1016/j.jse.2020.06.031DOI Listing
March 2021

Elbow motion patterns during daily activity.

J Shoulder Elbow Surg 2020 Oct 9;29(10):2007-2014. Epub 2020 Jun 9.

Investigation performed at the Roth|McFarlane Hand and Upper Limb Center, London, ON, Canada. Electronic address:

Background: This in vivo kinematic study was developed to ascertain (1) elbow posture and motion during daily activities and (2) to compare motions of the dominant and nondominant elbows.

Methods: Forty-six subjects wore a custom instrumented shirt to continuously measure elbow posture and motion for the waking hours of 1 day. The 3D orientations of each of the forearm and humerus sensors enabled calculation of elbow flexion-extension and pronation-supination angles.

Results: The elbow flexion-extension postures that were most common ranged from 60°-100° for both the dominant and nondominant extremities averaging 44% ± 4% and 35% ± 4% of the day, respectively. When elbow flexion motions were calculated, there were a large number of motions over a wide distribution of flexion angles, with the dominant side exhibiting significantly more motions per hour than the nondominant side.

Conclusion: Both flexion-extension and pronation-supination motions occur more commonly in the dominant arm, and the dominant arm is more commonly in pronation. These data provide a baseline for assessing treatment outcomes, ergonomic studies, and elbow arthroplasty wear testing.
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http://dx.doi.org/10.1016/j.jse.2020.03.015DOI Listing
October 2020

The influence of reverse arthroplasty humeral component design features on scapular spine strain.

J Shoulder Elbow Surg 2021 Mar 2;30(3):572-579. Epub 2020 Jul 2.

Investigations conducted at the Bioengineering Laboratory at the Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, ON, Canada. Electronic address:

Background: Reverse shoulder arthroplasty (RSA) humeral implant parameters have been previously studied with respect to range of motion, deltoid function, and stability. However, limited literature exists on the influence of humeral design features on scapular spine strain. The purpose of this cadaveric biomechanical simulator study was to evaluate the role of humeral component lateralization and neck-shaft angle (NSA) on scapular spine strain.

Methods: Eight fresh-frozen cadaveric shoulders were tested using an in vitro shoulder simulator. A custom-designed modular RSA system was implanted that allowed for the in situ adjustment of humeral lateralization and NSA. Scapular spine strain was measured by strain gauges placed along the acromion and scapular spine in clinically relevant positions representative of the Levy fracture zones. All testing was conducted in both abduction and forward elevation.

Results: In Levy zones 2 and 3, increasing humeral lateralization caused significant incremental decreases in scapular spine strain at 0° and 90° abduction (P < .042). Strain decreases as high as 34% were noted with increases in humeral lateralization from -5 to 15 mm (P = .042). Changing NSA had no statistically significant effect on scapular spine strain (P > .14).

Conclusions: Some humeral implant design features in RSA have effects on scapular spine strain. Humeral component lateralization had significant effects, whereas adjusting NSA resulted in no substantial differences in scapular spine strain. Understanding humeral component variables is important to allow for design optimization of future RSA implants.
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http://dx.doi.org/10.1016/j.jse.2020.06.011DOI Listing
March 2021

Investigating the Effects of Demographics on Shoulder Morphology and Density Using Statistical Shape and Density Modeling.

J Biomech Eng 2020 12;142(12)

Department of Mechanical Engineering, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada.

A better understanding of how the shape and density of the shoulder vary among members of a population can help design more effective population-based orthopedic implants. The main objective of this study was to develop statistical shape models (SSMs) and statistical density models (SDMs) of the shoulder to describe the main modes of variability in the shape and density distributions of shoulder bones within a population in terms of principal components (PCs). These PC scores were analyzed, and significant correlations were observed between the shape and density distributions of the shoulder and demographics of the population, such as sex and age. Our results demonstrated that when the overall body sizes of male and female donors were matched, males still had, on average, larger scapulae and thicker humeral cortical bones. Moreover, we concluded that age has a weak but significant inverse effect on the density within the entire shoulder. Weak and moderate, but significant, correlations were also found between many modes of shape and density variations in the shoulder. Our results suggested that donors with bigger humeri have bigger scapulae and higher bone density of humeri corresponds with higher bone density in the scapulae. Finally, asymmetry, to some extent, was noted in the shape and density distributions of the contralateral bones of the shoulder. These results can be used to help guide the designs of population-based prosthesis components and pre-operative surgical planning.
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http://dx.doi.org/10.1115/1.4047664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580668PMC
December 2020

In vivo reverse total shoulder arthroplasty contact mechanics.

J Shoulder Elbow Surg 2021 Feb 21;30(2):421-429. Epub 2020 Jun 21.

Imaging Research Laboratories, Robarts Research Institute, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada; Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Roth|McFarlane Hand and Upper Limb Center, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.

Background: Several in vitro studies have investigated the biomechanics of reverse total shoulder arthroplasty (RTSA); however, few in vivo studies exist. The purpose of this study was to examine in vivo RTSA contact mechanics in clinically relevant arm positions. Our hypothesis was that contact would preferentially occur in the inferior region of the polyethylene liner.

Methods: Forty patients receiving a primary RTSA were recruited for a prospective cohort study. All patients received the same implant design with a nonretentive liner. Stereo radiographs were taken at maximal active range of motion. Model-based radiostereometric analysis was used to identify implant position. Contact area between the polyethylene and glenosphere was measured as the geometric intersection of the 2 components and compared with respect to polyethylene liner size, arm position, and relative position within the liner.

Results: There were no differences in the proportion of contact area in any arm position between polyethylene liner sizes, ranging from 30% ± 17% to 38% ± 23% for 36-mm liners and 32% ± 21% to 41% ± 25% for 42-mm liners. Contact was equally distributed between the superior and inferior halves of the liner at each arm position (P = .06-.79); however, greater contact area was observed in the outer radius of the liner when the arm was flexed (P = .002).

Conclusion: This study highlights that contact mechanics are similar between 36- and 42-mm liners. Contact area is generally equally distributed throughout the liner across the range of motion and not preferentially in the inferior region as hypothesized.
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http://dx.doi.org/10.1016/j.jse.2020.05.036DOI Listing
February 2021

Static and Dynamic External Fixation are Equally Effective for Unstable Elbow Fracture-Dislocations.

J Orthop Trauma 2021 03;35(3):e82-e88

Department of Surgery, St. Joseph's Health Care, Hand and Upper Limb Centre, Western University, London, ON, Canada; and.

Objective: To compare the clinical outcomes of static versus dynamic external fixation for elbow fracture-dislocations with persistent instability after surgical management.

Design: Comparative, retrospective review.

Setting: Two tertiary referral upper-extremity centers.

Patients: Twenty-four elbows requiring external fixation for persistent elbow instability within 90 days of surgical management of an elbow fracture-dislocation.

Intervention: Static and dynamic external fixation was used in 16 and 8 patients, respectively, for a median of 39 days (interquartile range, 33-48 days).

Main Outcome Measurements: Elbow range of motion, complications, and revision surgeries.

Results: Immediately after static and dynamic external fixation removal, there was no difference in elbow extension [33 degrees ± 16 degrees vs. 41 degrees ± 13 degrees, mean difference (MD) 7 degrees, 95% confidence interval (CI) -6 degrees-22 degrees] or flexion (114 degrees ± 35 degrees vs. 118 degrees ± 11 degrees, MD 4 degrees, 95% CI -23 degrees-132 degrees), respectively. At last follow-up, static and dynamic external fixation groups had no difference in elbow extension (27 degrees ± 13 degrees vs. 24 degrees ± 10 degrees, MD -3 degrees, 95% CI -15 degrees-7 degrees) or flexion (129 degrees ± 12 degrees vs. 128 degrees ± 14 degrees, MD -1 degree, 95% CI -13 degrees-10 degrees), respectively. Static and dynamic external fixation groups had no difference in complications [7 (44%) vs. 5 (63%), difference 19%, 95% CI -23%-54%] or revision surgeries [6 (38%) vs. 4 (50%), difference 13%, 95% CI -27%-49%].

Conclusions: No difference in range of motion, complications, and revision surgeries was detected after static versus dynamic external fixation of persistently unstable elbow fracture-dislocations. Due to ease of application, static external fixation is our preferred treatment for these injuries.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001876DOI Listing
March 2021

The Application of Digital Volume Correlation (DVC) to Evaluate Strain Predictions Generated by Finite Element Models of the Osteoarthritic Humeral Head.

Ann Biomed Eng 2020 Dec 22;48(12):2859-2869. Epub 2020 Jun 22.

Department of Mechanical and Materials Engineering, Western University, London, ON, Canada.

Continuum-level finite element models (FEMs) of the humerus offer the ability to evaluate joint replacement designs preclinically; however, experimental validation of these models is critical to ensure accuracy. The objective of the current study was to quantify experimental full-field strain magnitudes within osteoarthritic (OA) humeral heads by combining mechanical loading with volumetric microCT imaging and digital volume correlation (DVC). The experimental data was used to evaluate the accuracy of corresponding FEMs. Six OA humeral head osteotomies were harvested from patients being treated with total shoulder arthroplasty and mechanical testing was performed within a microCT scanner. MicroCT images (33.5 µm isotropic voxels) were obtained in a pre- and post-loaded state and BoneDVC was used to quantify full-field experimental strains (≈ 1 mm nodal spacing, accuracy = 351 µstrain, precision = 518 µstrain). Continuum-level FEMs with two types of boundary conditions (BCs) were simulated: DVC-driven and force-driven. Accuracy of the FEMs was found to be sensitive to the BC simulated with better agreement found with the use of DVC-driven BCs (slope = 0.83, r = 0.80) compared to force-driven BCs (slope = 0.22, r = 0.12). This study quantified mechanical strain distributions within OA trabecular bone and demonstrated the importance of BCs to ensure the accuracy of predictions generated by corresponding FEMs.
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http://dx.doi.org/10.1007/s10439-020-02549-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723934PMC
December 2020

Evaluating the reproducibility of the short version of the Western Ontario Rotator Cuff Index (Short-WORC) prospectively.

JSES Int 2020 Mar 20;4(1):197-201. Epub 2019 Dec 20.

Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, ON, Canada.

Background: Recently, a shorter version of the Western Ontario Rotator Cuff Index (Short-WORC) was created to reduce patient response burden. However, it has yet to be evaluated prospectively for reproducibility (reliability and agreement) and floor and ceiling effects.

Methods: Patients (N = 162) with rotator cuff disorders completed the Short-WORC at baseline. From this cohort, 47 patients underwent measurement of test-retest reliability within 2 to 7 days. We used the Cronbach α to determine internal consistency and the intraclass correlation coefficient (ICC) to assess test-retest reliability. To evaluate parameters of agreement, the standard error of measurement, minimal detectable change (based on a 90% confidence interval), and Bland-Altman plots were used.

Results: The Cronbach α was 0.82 at baseline, and the intraclass correlation coefficient (ICC) was 0.87. The agreement parameter was 8.4 for the standard error of measurement of agreement, and the limits of agreement fell within the range of -22.9 to 23.8. The Short-WORC is reliable over time and reflective of a patient's true score after an intervention.

Conclusions: The Short-WORC demonstrated strong reproducibility parameters and can be used for patients with rotator cuff disorders. The Short-WORC indicated no systematic bias and was reflective of the true score of both individual patients and groups of patients at 2 time points.
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http://dx.doi.org/10.1016/j.jses.2019.10.110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075774PMC
March 2020

A multicenter, prospective 2-year analysis of the Sidus stem-free shoulder arthroplasty system.

JSES Int 2020 Mar 11;4(1):120-126. Epub 2019 Dec 11.

Department of Surgery, Queen's University, Kingston General Hospital, Kingston, ON, Canada.

Background: The purpose of this multicenter, prospective study was to evaluate the efficacy and safety of a stemless total shoulder arthroplasty compared with a traditional stemmed control.

Methods: Ninety-five shoulders were selected for participation in this Food and Drug Administration investigational device exemption clinical trial and underwent stemless total shoulder arthroplasty. Subjects returned for follow-up at 6 weeks, 6 months, 12 months, and 2 years postoperatively. Outcome measures included pain; range of motion; American Shoulder and Elbow Surgeons, Western Ontario Osteoarthritis of the Shoulder, and Short Form 12 scores; and radiographic review. Baseline data were compared with 2-year follow-up data to determine the rate of composite clinical success compared with the stemmed control.

Results: All outcome assessments demonstrated significant improvements ( ≤ .007). The mean American Shoulder and Elbow Surgeons score improved from 20 to 89 ( < .0001), and the mean shoulder pain score decreased from 8.3 ± 1.6 to 0.7 ± 1.5 ( < .0001). The mean Western Ontario Osteoarthritis of the Shoulder score decreased from 1443 ± 256 to 203 ± 267 ( < .0001). On the Short Form 12, the mean physical health score increased from 33 ± 7 to 48 ± 9 ( < .0001) and the mean mental health score increased from 50 ± 13 to 54 ± 8 ( = .007). Mean active forward elevation increased from 97° ± 27° to 143° ± 25° ( < .0001), and mean active external rotation increased from 21° ± 16° to 53° ± 18° ( < .0001). Kaplan-Meier analysis showed an implant survivorship rate of 98% at 2 years. The composite clinical success rate was 87% compared with 85% for the stemmed control.

Conclusions: This study showed that a stemless rough-blasted humeral implant with metaphyseal bone fixation provides good clinical and radiographic outcomes and survivorship at 2 years, with outcomes comparable to a traditional stemmed implant.
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http://dx.doi.org/10.1016/j.jses.2019.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075750PMC
March 2020

The evolution of virtual reality in shoulder and elbow surgery.

JSES Int 2020 Jun 7;4(2):215-223. Epub 2020 May 7.

Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada.

Virtual Reality (VR) in orthopedic surgery has significantly increased in popularity in the areas of preoperative planning, intraoperative usage, and for education and training; however, its utilization lags behind other surgical disciplines and industries. The use of VR in orthopedics is largely focused on education and is currently endorsed by North American and European training committees. The use of VR in shoulder and elbow surgery has varying levels of evidence, from I to IV, and typically involves educational randomized controlled trials. To date, however, the terms and definitions surrounding VR technology used in the literature are often redundant, confusing, or outdated. The purpose of this review, therefore, was to characterize previous uses of VR in shoulder and elbow surgery in preoperative, intraoperative, and educational domains including trauma and elective surgery. Secondary objectives were to provide recommendations for updated terminology of immersive VR (iVR) as well as provide a framework for standardized reporting of research surrounding iVR in shoulder and elbow surgery.
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http://dx.doi.org/10.1016/j.jseint.2020.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256885PMC
June 2020

Measurement Properties of the Brief Pain Inventory-Short Form (BPI-SF) and the Revised Short McGill Pain Questionnaire-Version-2 (SF-MPQ-2) in Pain-related Musculoskeletal Conditions: A Systematic Review Protocol.

Arch Bone Jt Surg 2020 Mar;8(2):131-141

Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada.

Background: The Brief Pain Inventory-Short Form (BPI-SF) and Revised Short-Form McGill Pain Questionnaire Version-2 (SF-MPQ-2) are generic pain assessment tools used in research and practice for pain assessment in musculoskeletal (MSK) conditions. A comprehensive review that systematically analyses their measurement properties in MSK conditions has not been performed. This review protocol describes the steps that will be taken to locate, critically appraise, compare and summarize clinical measurement research on the BPI-SF and SF-MPQ-2 in pain-related MSK conditions.

Methods: Medline, EMBASE, CINAHL and Scopus will be searched for publications that examine the measurement properties of the Brief Pain Inventory and Revised Short-Form McGill Pain Questionnaire Version-2. Two reviewers will independently screen citations (title, abstract and full text) and extract relevant data. The extensiveness, rigor, and quality of measurement property reports will be examined with a structured measurement studies appraisal tool, and with the updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. Findings will be descriptively summarized, and when possible, a meta-analysis will be performed.

Discussion: This review will summarize and compare the current level of evidence on the measurement properties of the BPI-SF and SF-MPQ-2 in a spectrum of musculoskeletal conditions. We expect clinicians/researchers dealing with MSK conditions to have synthesized evidence that informs their decision making and preferences. In addition, the review hopes to identify gaps and determine priorities for future research with or on the BPI-SF and SF-MPQ-2 in MSK conditions.
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http://dx.doi.org/10.22038/abjs.2020.36779.1973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191979PMC
March 2020

How to Optimize Reverse Shoulder Arthroplasty for Irreparable Cuff Tears.

Curr Rev Musculoskelet Med 2020 Oct;13(5):553-560

Roth McFarlane Centre, London, ON, Canada.

Purpose Of The Review: Reverse shoulder arthroplasty (RSA) is commonly considered as one of the options for surgical management of the functionally irreparable rotator cuff tear (FIRCT). This article reviews tips and tricks to optimize the outcome of RSA when performed specifically for this indication.

Recent Findings: RSA has been reported to provide satisfactory outcomes in a large proportion of patients with FIRCTs. However, subjective satisfaction is lesser in patients with well-maintained preoperative motion as well as those with isolated loss of active external rotation. The popularity of implants that provide some degree of global lateralization continues to increase. Optimizing the outcome of RSA for FIRCTs requires a careful balance between minimizing perimeter impingement and enhancing the function of intact muscles, in particular the deltoid and any remaining rotator cuff. Controversy continues regarding the benefits and disadvantages of subscapularis repair at the time of RSA. Tendon and muscle transfers performed at the time of RSA have the potential to optimize the outcome in selected patients with profound weakness in external rotation or those with severe deltoid dysfunction. When RSA is considered for patients with a FIRCT without arthritis, careful attention to indications and technical pearls may contribute to optimize outcomes.
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http://dx.doi.org/10.1007/s12178-020-09655-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474717PMC
October 2020

Is preoperative planning effective for intraoperative glenoid implant size and type selection during anatomic and reverse shoulder arthroplasty?

J Shoulder Elbow Surg 2020 Oct 25;29(10):2123-2127. Epub 2020 Apr 25.

The Roth|McFarlane Hand and Upper Limb Centre, St Joseph's Hospital, London, ON, Canada.

Introduction: Preoperative 3D planning programs for anatomic (TSA) and reverse total shoulder arthroplasty (RSA) allow the analysis of glenohumeral joint pathoanatomy and templating for implant size selection and placement. The aim of this multicenter study was to compare the preoperative glenoid implant type and size planned to the final glenoid implant type and size used intraoperatively.

Methods: Two hundred patients (100 TSA and 100 RSA) with a mean age of 72 years who had undergone preoperative planning and subsequent shoulder arthroplasty (100 TSA and 100 RSA) were included. All preoperative plans were saved and were analyzed for arthroplasty type (TSA vs. RSA), implant type (augment vs. nonaugment), and size (ie, polyethylene size, polyethylene radius of curvature, glenoid baseplate diameter, baseplate post length, and baseplate lateralization). The preoperative plan was available during surgery and was compared to the final implants inserted by the surgeon.

Results: There were no intraoperative conversions of TSA to RSA or vice versa. In patients planned for a TSA, complete concordance between the preoperative plan and final implant selection was 85%. A complete mismatch for TSA glenoid size, backside radius of curvature, and augmentation occurred in 2%. For RSA, complete concordance was found in 90% of cases. A complete mismatch for implant type, size, post length, and glenosphere size occurred in 3%.

Conclusion: A high concordance was found between preoperative 3D planning implant selection and the glenoid component inserted at surgery for TSA and RSA. This high concordance may assist with surgical preparedness, implant stocks, and possibly future implant production.
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http://dx.doi.org/10.1016/j.jse.2020.01.098DOI Listing
October 2020

Outcomes of scapulothoracic fusion in facioscapulohumeral muscular dystrophy: A systematic review.

Shoulder Elbow 2020 Apr 14;12(2):75-90. Epub 2019 Aug 14.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada.

Background: Facioscapulohumeral muscular dystrophy (FSHD) is a rare condition associated with selective weakness of the muscles of the upper arm, face, and shoulder girdle, negatively affecting daily activities. Scapulothoracic arthrodesis may restore shoulder function and improve quality of life. The purpose of this review is to evaluate the outcomes and complications of scapulothoracic arthrodesis in FSHD patients.

Methods: Medline, Pubmed, and Embase were systematically searched. Studies were included if they described scapulothoracic arthrodesis in FSHD with follow-up, and outcomes were adequately reported. Thirteen eligible articles reported the outcomes of 199 arthrodesis in 130 patients.

Results: The mean gain of shoulder forward elevation and abduction were 45° (p < 0.05) and 40° (p < 0.05), respectively. There was an overall cosmetic satisfaction and improved performance of daily activities. There is limited and heterogeneous data on changes in pulmonary function, but such changes are clinically insignificant. The rate of complications was 41% of which 10% were serious, requiring an intervention or re-admission. The most common complications were hardware failure (8%), non-union (6%), and pneumothorax (5%).

Discussion: Scapulothoracic arthrodesis improved cosmesis, performance of daily activities and shoulder motion with no clinically significant loss of pulmonary function. The complication rate is high, and some are potentially serious.
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http://dx.doi.org/10.1177/1758573219866195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153204PMC
April 2020

Interpretation and content validity of the items of the numeric rating version short-WORC to evaluate outcomes in management of rotator cuff pathology: a cognitive interview approach.

Health Qual Life Outcomes 2020 Mar 30;18(1):88. Epub 2020 Mar 30.

Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, ON, Canada.

Background: The shortened version of the Western Ontario Rotator Cuff Index (Short-WORC) is a patient reported outcome measure that evaluates quality of life (QoL) of patients with rotator cuff pathology. However, formal content validation of the full or Short-WORC has not been reported. This study aims to understand how 1) people interpret and calibrate responses to items on the Short-WORC and 2) compensatory strategies that might enhance function and thereby affect responses.

Methods: This study uses cognitive interviewing, a qualitative methodology that focuses on the interpretation of questionnaire items. Patients with rotator cuff disorders (n = 10), clinicians (n = 6) and measurement researchers (n = 10) were interviewed using a talk aloud structured interview that evaluated each of the 7 items of the Short-WORC. All interviews were recorded and transcribed verbatim by one researcher (R.F). Analysis was done through an open coding scheme using a previously established framework.

Results: Overall, the items on the Short-WORC were well received by participants. Through the interviews, the 6 themes of: Comprehension, Inadequate response definition, Reference Point, Relevance, Perspective Modifiers and Calibration Across Items emerged. The items of working above the shoulder (90%), compensating with the unaffected arm (88%) and lifting heavy objects (92%) were the most relevant to participants. Participants calibrated their scores on the items of sleeping and styling (19%) the most. Perspective modifiers of gender, influenced the calibrations of items of styling your hair (30%) and dressing or undressing (19%). Compensatory strategies of task-re allocation and using assistive devices/resources were frequently mentioned by participants. Overall, participants had minor comprehension issues, but found the 7- items of the Short-WORC to be relevant to QoL.

Conclusions: Therefore, the findings demonstrate that the Short-WORC is not cognitively complex, but varies with patient perspectives. Overall, the Short-WORC provides evidence of demonstrating strong content validity when used for rotator cuff disorder patients.
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http://dx.doi.org/10.1186/s12955-020-01339-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106799PMC
March 2020

Short stem humeral components in reverse shoulder arthroplasty: stem alignment influences the neck-shaft angle.

Arch Orthop Trauma Surg 2021 Feb 27;141(2):183-188. Epub 2020 Mar 27.

OCM (Orthopädische Chirurgie München) Clinic, Steinerstraße 6, 81369, München, Germany.

Introduction: Shorter humeral reverse total shoulder arthroplasty (RTSA) stems may reduce stress shielding, however, potentially carry the risk of varus/valgus malalignment. This radiographic study's purpose was to measure the incidence of stem malalignment and thus the realized neck-shaft angle (NSA). The hypothesis was that malalignment of the stem is a frequent postoperative radiographic finding.

Methods: Radiographs of an uncemented curved short stem RTSA with a 145° NSA were reviewed. The study group included 124 cases at a mean age of 74 (range 48-91) years. The humeral stem axis was measured and defined as neutral if the value fell within ± 5° of the longitudinal humeral axis. Angular values > 5° were defined as malaligned in valgus or varus. The filling ratio of the implant within the humeral shaft was measured at the level of the metaphysis (FR) and diaphysis (FR).

Results: The average humeral stem axis angle was 4 ± 3° valgus, corresponding to a true mean NSA of 149 ± 3°. Stem axis was neutral in 73% (n = 90) of implants. Of the 34 malaligned implants, 82% (n = 28) were in valgus (NSA = 153 ± 2°) and 18% (n = 6) in varus (NSA = 139 ± 1°). The average FR and FR were 0.68 ± 0.11 and 0.72 ± 0.11, respectively. A low positive association was found between stem diameter and filling ratios (r = 0.39; p < 0.001); indicating smaller stem sizes were more likely to be misaligned.

Conclusion: Uncemented short stem implants may decrease stress shielding; however, approximately one quarter were implanted > 5° malaligned. The majority of malaligned components (86%) were implanted in valgus, corresponding to an NSA of > 150°. As such, surgeons must be aware that shorter and smaller stems may lead to axial malalignment influencing the true SA.

Level Of Evidence: Level IV, retrospective study.
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http://dx.doi.org/10.1007/s00402-020-03424-4DOI Listing
February 2021

Osteoarticular distal clavicle autograft for the management of instability-related glenoid bone loss: an anatomic and cadaveric study.

J Shoulder Elbow Surg 2020 Aug 17;29(8):1615-1620. Epub 2020 Mar 17.

Mechatronics Laboratory, Roth|McFarlane Hand and Upper Limb Center, London, ON, Canada. Electronic address:

Background: The reconstructive options for instability-related anterior glenoid bone loss include iliac crest autograft, allograft, or coracoid transfer. The use of distal clavicle autograft (DCG) has also been described. The purpose of this imaging and cadaveric study was to examine the dimensions, morphology, and bone density of the DCG and compare it with the Latarjet procedure.

Methods: We used 49 computed tomography scans from patients with anterior glenoid bone loss to measure the distal clavicle dimensions and bone density. Four glenoid reconstructions were simulated to compare techniques: DCG inferior surface toward glenoid (DCG inferior), DCG superior, classic Latarjet, and congruent-arc Latarjet. In addition, the morphology of the DCG was assessed on computed tomography and confirmed in 27 cadavers.

Results: The mean width of the DCG (11 mm) was significantly greater (P < .001) than that of the classic Latarjet orientation (9 mm) but less (P = .002) than that of the congruent-arc orientation (12 mm). The DCG had a lower bone density than the coracoid (P < .001). The mean articular surface area of the DCG-inferior orientation was 208 mm, which was greater (P = .013) than that of the DCG-superior orientation (195 mm) and not significantly different (P = .44) than that of the classic Latarjet orientation (214 mm). The surface area of the congruent-arc orientation was greater (285 mm, P < .001) than that of all other graft orientations. The DCG-inferior orientation was able to reconstruct 22% of the glenoid articular surface; DCG-superior orientation, 21%; classic Latarjet orientation, 23%; and congruent-arc orientation, 30%. Three DCG morphologies were identified: square (34%), trapezoidal (53%), and rounded (13%).

Conclusions: The distal clavicle osteoarticular graft was able to reconstruct 22% of the glenoid face. Three morphologies of the distal clavicle were identified, with the square and trapezoidal morphologies most amenable for glenoid reconstruction.
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http://dx.doi.org/10.1016/j.jse.2019.12.027DOI Listing
August 2020

Radial head arthroplasty: fixed-stem implants are not all equal-a systematic review and meta-analysis.

JSES Int 2020 Mar 29;4(1):30-38. Epub 2020 Feb 29.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.

Background: Numerous fixed-stem implants exist for radial head arthroplasty; therefore, we conducted a systematic review to compare the safety and efficacy of different types of fixed-stem implants.

Methods: We conducted a literature search, updated from a previous systematic review, to identify studies evaluating a fixed-stem radial head arthroplasty implant for any indication. We extracted data on revision rates, specific complications, and functional scores. We pooled results across studies using a random-effects method, using proportions for dichotomous data and mean values for functional scores. We analyzed outcomes by indication and specific implant.

Results: We included 31 studies. Studies included patients with radial head fractures only, terrible-triad injuries, or Essex-Lopresti injuries or included a heterogeneous population. We identified 15 different fixed-stem implants. The results of our analysis revealed that patients with terrible-triad injuries may be at an increased risk of revision and instability and patients with Essex-Lopresti injuries may be at an increased risk of arthritis, capitellar erosion, and osteolysis. After removing these outliers and pooling the results by specific device, we observed variability across devices in the rates of revision, arthritis, capitellar erosion, instability, and osteolysis, as well as in functional scores.

Conclusion: Differences were seen across different implants in revision rates, certain complications, and functional scores. This study highlighted that these devices should be evaluated within the context of the patient population under examination, as patients with Essex-Lopresti or terrible-triad injuries may demonstrate worse outcomes relative to those with a fracture only.
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http://dx.doi.org/10.1016/j.jseint.2019.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075758PMC
March 2020

In vivo volumetric and linear wear measurement of reverse shoulder arthroplasty at minimum 5-year follow-up.

J Shoulder Elbow Surg 2020 Aug 16;29(8):1695-1702. Epub 2020 Mar 16.

Imaging Research Laboratories, Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Electronic address:

Background: Reverse shoulder arthroplasty is quickly becoming the most frequently performed glenohumeral joint replacement. The purpose of this study was to evaluate the volumetric and linear wear rates of ultrahigh-molecular-weight polyethylene humeral liners in vivo at a minimum 5-year follow-up.

Methods: Radiostereometric analysis was used to image 15 patients at terminal range of motion in forward flexion, abduction, external rotation, and internal rotation and with the arm at the side. The relative position and orientation of the glenosphere and polyethylene were identified for each arm position. The apparent intersection of the glenosphere into the polyethylene was recorded as wear. Mean volumetric and linear wear rates were recorded, and Pearson correlation coefficients were applied to the 36-mm liners to assess the relationship between the wear rate and term of service.

Results: The mean reverse shoulder arthroplasty term of service at the time of imaging was 8 ± 1 years (range, 6-11 years). The mean volumetric and linear wear rates for the 36-mm liners (n = 13) were 42 ± 22 mm/yr (r = 0.688, P = .009) and 0.11 ± 0.03 mm/yr (r = 0.767, P = .002), respectively. The mean volumetric and linear wear rates for the 42-mm liners (n = 2) were 114 ± 44 mm/yr and 0.17 ± 0.01 mm/yr, respectively. No single arm position was able to capture all recorded wear individually.

Conclusion: This study showed volumetric and linear wear rates of approximately 40 mm/yr and 0.1 mm/yr, respectively, for the 36-mm polyethylene liners. The 42-mm liners showed higher wear rates, although a greater number of subjects is required for conclusive results. In vivo wear of reverse total shoulder arthroplasty is multidirectional and perceptible.
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http://dx.doi.org/10.1016/j.jse.2019.11.031DOI Listing
August 2020

Revision shoulder arthroplasty: a systematic review and comparison of North American vs. European outcomes and complications.

J Shoulder Elbow Surg 2020 May 5;29(5):1071-1082. Epub 2020 Mar 5.

Department of Surgery, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Josephs Health Care, London, ON, Canada. Electronic address:

Background: Joint registries provide invaluable data on primary arthroplasties with revision as the endpoint; however, the revision outcomes are often excluded. Therefore, a PROSPERO registered review (CRD42015032531) of all revision studies in North America and Europe was conducted to evaluate demographics, etiologies and indications, implant manufacturer, and complications by geographic region.

Methods: The MEDLINE, EMBASE, and CENTRAL databases were searched for revision arthroplasty clinical studies with a minimum mean 24-month follow-up. There were no language exclusions. Articles published in German, French, and Italian were reviewed by research personnel proficient in each language.

Results: The mean age at revision was 66 ± 5 years (male = 759, female = 1123). The male-female ratio in North American and Europeans studies was 43:57 and 34:66, respectively. The most common etiology for primary surgery in both regions was osteoarthritis or glenoid arthrosis (38%). The most common revision indication overall was rotator cuff tear, deficiency, or arthropathy (26%). The most common implant type used in revisions was a reverse shoulder arthroplasty (54%). The complication rate for all revisions was 17%. There were a total of 465 complications, and of those, 74% lead to a reoperation.

Conclusion: Generally, shoulder arthroplasties are designed to last 10-15 years; however, revisions are being performed at a mean 3.9 years from the primary procedure, based on the published studies included in this systematic review. Additionally, of the complications, a large number (74%) went on to a reoperation. Further insight into the reasons for early revisions and standardized reporting metrics and data collection on revisions is needed.
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http://dx.doi.org/10.1016/j.jse.2019.12.015DOI Listing
May 2020

Surgical stabilization of pediatric anterior shoulder instability yields high recurrence rates: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2021 Jan 28;29(1):192-201. Epub 2020 Feb 28.

Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.

Purpose: The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability.

Methods: The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies.

Results: Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%).

Conclusions: Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-05913-wDOI Listing
January 2021

Type E2 glenoid bone loss orientation and management with augmented implants.

J Shoulder Elbow Surg 2020 Jul 12;29(7):1460-1469. Epub 2020 Feb 12.

Roth|McFarlane Hand and Upper Limb Centre, St Joseph's Hospital, London, ON, Canada; Department of Surgery, Western University, London, ON, Canada; Division of Orthopaedic Surgery, London Health Sciences Center, London, ON, Canada. Electronic address:

Background: The purpose of this study was 2-fold: (1) to quantify type E2 bone loss orientation and its association with rotator cuff fatty infiltration and (2) to examine reverse baseplate designs used to manage type E2 glenoids.

Methods: Computed tomography scans of 40 patients with type E2 glenoids were examined for pathoanatomic features and erosion orientation. The rotator cuff fatty infiltration grade was compared with the erosion orientation angle. To compare reconstructive options in light of the pathoanatomic findings, virtual implantation of 4 glenoid baseplate designs (standard, half wedge, full wedge, and patient-matched) was conducted to determine the volume of bone removal for seating and impingement-free range of motion.

Results: The mean type E2 erosion orientation angle was 47° ± 17° from the 0° superoinferior glenoid axis, resulting in the average erosion being located in the posterosuperior quadrant directed toward the 10:30 clock-face position. The type E2 neoglenoid, on average, involved 67% of the total glenoid surface (total surface area, 946 ± 209 mm; neoglenoid surface area, 636 ± 247 mm). The patient-matched baseplate design resulted in significantly (P ≤ .01) less bone removal (200 ± 297 mm) for implantation, followed by the full-wedge design (1228 ± 753 mm), half-wedge design (1763 ± 969 mm), and standard (non-augmented) design (4009 ± 1210 mm). We noted a marked difference in erosion orientation toward a more superior direction as the subscapularis fatty infiltration grade increased from grade 3 to grade 4 (P < .001).

Conclusion: The average type E2 erosion orientation was directed toward the 10:30 clock-face position in the posterosuperior glenoid quadrant. This orientation resulted in the patient-matched glenoid augmentation requiring the least amount of bone removal for seating, followed by the full-wedge, half-wedge, and standard designs. Implant selection also substantially affected computationally derived range of motion in external rotation, flexion, extension, and adduction.
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http://dx.doi.org/10.1016/j.jse.2019.11.009DOI Listing
July 2020

Cross-cultural adaptions and measurement properties of the WORC (Western Ontario rotator cuff index): a systematic review.

Health Qual Life Outcomes 2020 Jan 29;18(1):17. Epub 2020 Jan 29.

Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, ON, Canada.

Background: To evaluate the translations, cross-cultural adaptation procedures and measurement properties of the Western Ontario Rotator Cuff Index (WORC), when it is adapted for different cultures.

Methods: A systematic review was performed, considering different cultural adaptions of the WORC accessible through MEDLINE, CINAHL, EMBASE and/or Google Scholar. Included were prospective cohort studies that used an adapted version of the WORC to measure QoL in patients with rotator cuff disorders. All studies were evaluated according to the current guidelines for cross-cultural adaptations and measurement properties.

Results: The search retrieved 14 studies that met the inclusion criteria. According to the recommended guidelines for cross-cultural adaptations, 8 studies performed 100% of the steps, 2 studies performed 80% of the steps and 4 studies used previously translated measures. When evaluating the studies' psychometric properties based on the quality criteria, none of the studies reported all recommended measurement properties. All of the studies reported the measurement property of reliability, but none of the studies reported agreement. Internal consistency was fully reported by 15% of studies. Construct validity was reported by 43% of studies. Only one study reported 100% of the cross-cultural adaption guidelines and 83% of the quality criteria.

Conclusions: Although the majority of studies demonstrated proper adaptation procedures, testing of the measurement properties were inadequate. It is recommended that the current adapted versions of the WORC undergo further testing before use in clinical practise, and researchers continue to adapt the WORC for different cultures as it proves to be an appropriate instrument for assessing rotator cuff pathology.
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http://dx.doi.org/10.1186/s12955-020-1276-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988228PMC
January 2020

The arthroscopic Latarjet: a multisurgeon learning curve analysis.

J Shoulder Elbow Surg 2020 Apr 22;29(4):681-688. Epub 2020 Jan 22.

Brighton and Sussex Medical School, Brighton, UK; Trauma and Orthopaedics Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.

Background: The open Latarjet procedure is a standard surgical treatment option for anterior shoulder instability in patients with a high risk of failure following soft tissue stabilization. The arthroscopic technique has potential advantages of minimal invasiveness, reduced postoperative stiffness, and faster rehabilitation but is regarded as technically challenging with concern over surgical risk during the learning curve. The aim of this study was to undertake a multisurgeon, large-volume learning curve analysis of the arthroscopic Latarjet procedure using continuous learning curve analysis.

Methods: Individual patient data from 12 surgeons across 5 countries were retrospectively reviewed. A total of 573 patients undergoing the arthroscopic Latarjet procedure were included. Outcome measures of learning were collected, including operative time, computed tomography (CT) bone-block positioning, complications, and patient-reported outcome measures (PROMs). A segmented linear regression modeling technique was used for learning curve analysis.

Results: High-volume surgeons converged to an operative time steady state after 30-50 cases. Surgeons completing fewer procedures demonstrated a constant reduction in operative time without reaching a plateau. Low-volume surgeons completing fewer than 14 operations did not demonstrate a reduction in operative time. Accuracy of bone-block positioning on postoperative CT demonstrated constant improvement without reaching a plateau after 53 cases. There was no change in PROMs or complications with increased operative volume.

Conclusion: Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning. Only surgeons expecting to undertake the arthroscopic Latarjet in high volume should consider adopting this procedure.
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http://dx.doi.org/10.1016/j.jse.2019.10.022DOI Listing
April 2020

Improved Complex Skill Acquisition by Immersive Virtual Reality Training: A Randomized Controlled Trial.

J Bone Joint Surg Am 2020 03;102(6):e26

Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.

Background: There has been limited literature on immersive virtual reality (VR) simulation in orthopaedic education. The purpose of this multicenter, blinded, randomized controlled trial was to determine the validity and efficacy of immersive VR training in orthopaedic resident education.

Methods: Nineteen senior orthopaedic residents (resident group) and 7 consultant shoulder arthroplasty surgeons (expert group) participated in the trial comparing immersive VR with traditional learning using a technical journal article as a control. The examined task focused on achieving optimal glenoid exposure. Participants completed demographic questionnaires, knowledge tests, and a glenoid exposure on fresh-frozen cadavers while being examined by blinded shoulder arthroplasty surgeons. Training superiority was determined by the outcome measures of the Objective Structured Assessment of Technical Skills (OSATS) score, a developed laboratory metric, verbal answers, and time to task completion.

Results: Immersive VR had greater realism and was superior in teaching glenoid exposure than the control (p = 0.01). The expert group outperformed the resident group on knowledge testing (p = 0.04). The immersive VR group completed the learning activity and knowledge tests significantly faster (p < 0.001) at a mean time (and standard deviation) of 11 ± 3 minutes than the control group at 20 ± 4 minutes, performing 3 to 5 VR repeats for a reduction in learning time of 570%. The immersive VR group completed the glenoid exposure significantly faster (p = 0.04) at a mean time of 14 ± 7 minutes than the control group at 21 ± 6 minutes, with superior OSATS instrument handling scores (p = 0.03). The immersive VR group scored equivalently in surprise verbal scores (p = 0.85) and written knowledge scores (p = 1.0).

Conclusions: Immersive VR demonstrated substantially improved translational technical and nontechnical skills acquisition over traditional learning in senior orthopaedic residents. Additionally, the results demonstrate the face, content, construct, and transfer validity for immersive VR.

Clinical Relevance: This adequately powered, randomized controlled trial demonstrated how an immersive VR system can efficiently (570%) teach a complex surgical procedure and also demonstrate improved translational skill and knowledge acquisition when compared with a traditional learning method.
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http://dx.doi.org/10.2106/JBJS.19.00982DOI Listing
March 2020

A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty.

J Shoulder Elbow Surg 2020 Feb 25;29(2):225-234. Epub 2019 Nov 25.

Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, ON, Canada; University of Western Ontario, London, ON, Canada.

Background: Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty.

Methods: Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events.

Results: We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months' follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99).

Discussion: No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.
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http://dx.doi.org/10.1016/j.jse.2019.09.028DOI Listing
February 2020

Development and Application of a Novel Metric to Characterize Comprehensive Range of Motion of Reverse Total Shoulder Arthroplasty.

J Orthop Res 2020 04 22;38(4):880-887. Epub 2019 Nov 22.

Department of Mechanical Engineering, Thomas J. Watson School of Engineering and Applied Science, State University of New York at Binghamton, Binghamton, New York.

Active range of motion (ROM) of reverse total shoulder arthroplasty (rTSA) can be limited by bony impingement, muscle inability, and joint instability. The aim of this study was to develop a novel metric representative of comprehensive ROM of rTSA, which is evaluated in the context of all three factors. It was hypothesized that the metric, termed global circumduction ROM (GC-ROM), would capture differences resulting from directional changes in rTSA design parameters known to increase ROM. GC-ROM was calculated for a set of 18 rTSA configurations with humeral polyethylene cup depths of 6 and 8.1 mm, glenosphere lateralization (GLat) distances of 0, 5, and 10 mm, and neck-shaft angles (NSA) of 135°, 145°, and 155°. For any implant configuration, arm positions were defined by internal/external (IE) rotation angle and two spherical coordinates representing the elevation plane angle and elevation angle. At each IE rotation angle, incremental positions with variable elevation plane and elevation angles were checked for feasibility based on impingement, muscle ability, and risk of instability. Coordinates of feasible positions were mapped to unit spheres and connected to form regions, of which the surface area was calculated to represent allowable circumduction ROM. ROMs were averaged across all IE rotation angles to produce a single metric, GC-ROM. The results showed that decreasing cup depth and increasing GLat and NSA increased GC-ROM. In conclusion, a novel metric to characterize comprehensive ROM, evaluated based on several ROM-limiting factors, was developed as a performance metric through which rTSA designs can be compared. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:880-887, 2020.
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http://dx.doi.org/10.1002/jor.24518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071975PMC
April 2020

Effects of arthroscopic vs. mini-open rotator cuff repair on function, pain & range of motion. A systematic review and meta-analysis.

PLoS One 2019 31;14(10):e0222953. Epub 2019 Oct 31.

Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, ON Canada.

Objective: To assess the effectiveness of arthroscopic versus mini-open rotator cuff repair on function, pain and range of motion at 3-, 6- and 12-month follow ups.

Design: Systematic review and meta-analysis of randomized controlled trials.

Setting: Clinical setting.

Participants: Patients 18 years and older with a rotator cuff tear.

Intervention/comparison: Arthroscopic/mini-open rotator cuff repair surgery followed by post operative rehabilitation.

Main Outcome Measures: Function and pain.

Results: Six RCTs (n = 670) were included. The pooled results, demonstrated no significant difference between arthroscopic and mini open approach to rotator cuff repair on function (very low quality, 4 RCTs, 495 patients, SMD 0.00, 3-month; very low quality, 4 RCTs, 495 patients, SMD -0.01, 6-month; very low quality, 3 RCTs, 462 patients, SMD -0.09, 12-months). For pain, the pooled results, were not statistically different between groups (very low quality, 3 RCTs, 254 patients, MD -0.21, 3-month; very low quality, 3 RCTs, 254 patients, MD -0.03, 6-month; very low quality, 2 RCTs, 194 patients, MD -0.35, 12-months).

Conclusion: The effects of arthroscopic compared to mini-open rotator cuff repair, on function, pain and range of motion are too small to be clinically important at 3-, 6- and 12-month follow ups.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822715PMC
March 2020

Management of rheumatoid arthritis of the elbow with a convertible total elbow arthroplasty.

J Shoulder Elbow Surg 2019 Nov;28(11):2205-2214

St Joseph's Hospital, Roth | McFarlane Hand & Upper Limb Center, London, ON, Canada. Electronic address:

Background: Total elbow arthroplasty (TEA) is commonly performed in patients with rheumatoid arthritis (RA). The purpose of this study was to compare outcomes and complications of unlinked and linked TEA using a convertible system in patients with RA.

Methods: All patients with RA who underwent TEA at a single center with a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome scores, functional outcome assessments, and radiographic parameters were evaluated at most recent follow-up.

Results: We evaluated 82 patients (27 with unlinked TEA and 55 with linked TEA) with RA. The mean age at surgery was 61 ± 10 years, with a mean follow-up period of 6 ± 4 years. Demographic characteristics were similar between groups, with the exception of longer follow-up in the unlinked group (8 years vs. 5 years, P = .001). No differences in range of motion were noted. Elbow strength was similar other than pronation strength (74% ± 8% for unlinked vs. 100% ± 8% for linked, P = .03). The mean Mayo Elbow Performance Index was 83 ± 16; Patient Rated Elbow Evaluation score, 15 ± 18; and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score, 34 ± 20. No differences in the rates of reoperation (17% vs. 24%, P = .4), complications (32% vs. 31%, P = .4), or revisions (13% vs. 17%, P = .3) were found between unlinked and linked devices. Four patients with instability, all with unlinked designs, underwent revision to a linked design. Four patients, all with linked designs, underwent revision for aseptic loosening of smooth short-stem ulnar components.

Conclusion: TEA using a convertible implant design provides good patient-reported outcomes at mid-term follow-up in patients with RA. Our study was unable to detect a difference in the use of either unlinked or linked implant designs; further large comparison trials are needed.
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http://dx.doi.org/10.1016/j.jse.2019.07.029DOI Listing
November 2019

Morphological and Apparent-Level Stiffness Variations Between Normal and Osteoarthritic Bone in the Humeral Head.

J Orthop Res 2020 03 6;38(3):503-509. Epub 2019 Oct 6.

School of Biomedical Engineering, The University of Western Ontario, London, Ontario, Canada.

Osteoarthritis (OA) is characterized by morphological changes that alter bone structure and mechanical properties. This study compared bone morphometric parameters and apparent modulus between humeral heads excised from end-stage OA patients undergoing total shoulder arthroplasty (n = 28) and non-pathologic normal cadavers (n = 28). Morphometric parameters were determined in central cores, with regional variations compared in four medial to lateral regions. Linear regression compared apparent modulus, morphometric parameters, and age. Micro finite element models estimated trabecular apparent modulus and derived density-modulus relationships. Significant differences were found for bone volume fraction (p < 0.001) and trabecular thickness (p < 0.001) in the most medial regions. No significant differences occurred between morphometric parameters and apparent modulus or age, except in slope between groups for apparent modulus versus trabecular number (p = 0.021), and in intercept for trabecular thickness versus age (p = 0.040). Significant differences occurred in both slope and intercept between density-modulus regression fits for each group (p ≤ 0.001). The normal group showed high correlations in the power-fit (r  = 0.87), with a lower correlation (r  = 0.61) and a more linear relationship, in the OA group. This study suggests that alterations in structure and apparent modulus persist mainly in subchondral regions of end-stage OA bone. As such, if pathologic regions are removed during joint replacement, computational models that utilize modeling parameters from non-pathologic normal bone may be applied to end-stage OA bone. An improved understanding of humeral trabecular bone variations has potential to improve the surgical management of end-stage OA patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:503-509, 2020.
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http://dx.doi.org/10.1002/jor.24482DOI Listing
March 2020
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