Publications by authors named "Jacob M Kirsch"

29 Publications

  • Page 1 of 1

Single Assessment Numeric Evaluation Correlates with American Shoulder and Elbow Surgeons Score for Common Elbow Pathology: A Retrospective Cohort Study.

Am J Sports Med 2021 Jun 25:3635465211024253. Epub 2021 Jun 25.

Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.

Background: There are currently a variety of patient-reported outcomes (PROs) for elbow pathology, without any established gold standard. The Single Assessment Numeric Evaluation (SANE) is a single question assessment of the patient's perceived overall function compared with normal. The SANE score has been correlated with PROs from the shoulder and knee literature.

Purpose: To correlate the SANE score for a variety of elbow pathologies with a traditionally reported elbow outcome measure, the American Shoulder and Elbow Surgeons-Elbow score (ASES-E).

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

Methods: A retrospective review was performed of all patients identified at a single center between April 2016 and January 2019 who presented as a new patient with elbow pathology. All patients prospectively completed the ASES-E along with the SANE score for elbow (SANE-E) at the time of initial consultation. Spearman correlations () were performed to evaluate the correlation between the ASES-E and the SANE-E score for specific elbow pathology, along with descriptive data such as age, sex, and chronicity of the problem.

Results: A total of 555 patients (166 women, 29.9%) with a mean ± SD age of 51.0 ± 11.7 years with the diagnoses of medial epicondylitis (n = 72; 13.0%), lateral epicondylitis (n = 224; 40.4%), biceps tendon rupture (n = 139; 25.0%), triceps tendon rupture (n = 21; 3.8%), and elbow arthritis (n = 99; 17.8%) were included in this analysis. There was moderate correlation between the SANE-E and the ASES-E ( = 0.623; < .001), with strongest correlation with the visual analog scale (VAS) ( = -0.518; < .001) compared with any individual question and moderate to strong correlations based on specific diagnoses. SANE-E and ASES-E scores for the entire cohort were 42.9 ± 26.7 and 56.9 ± 21.4, respectively ( < .001). Age ( = 0.027; = .526), sex ( = 0.026; = .555), VAS ( = -0.106; = .013), and chronicity of the problem ( = -0.037; = .384) were not found to be correlated with differences in ASES-E and SANE-E.

Conclusion: The SANE-E score is a simple way to assess patient-perceived function relative to normal. The findings of this study demonstrated moderate to strong correlation between the ASES-E and the SANE-E score for a variety of commonly encountered elbow conditions.
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http://dx.doi.org/10.1177/03635465211024253DOI Listing
June 2021

Functional somatic syndromes are associated with suboptimal outcomes and high cost after shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jun 9. Epub 2021 Jun 9.

Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA. Electronic address:

Background: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs.

Methods: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores.

Results: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001).

Conclusions: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.
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http://dx.doi.org/10.1016/j.jse.2021.05.015DOI Listing
June 2021

Acromion and Scapular Spine Fractures Following Reverse Total Shoulder Arthroplasty.

Orthop Clin North Am 2021 Jul 7;52(3):257-268. Epub 2021 May 7.

Department of Orthopaedic Surgery, New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA; Boston Sports and Shoulder Center, 840 Winter Street, Waltham, MA 02451, USA.

Reverse total shoulder arthroplasty (RSA) continues to see tremendous growth as the indications have expanded. A variety of complications have been described, including fractures of the acromion or scapular spine. These fractures are painful and can compromise shoulder stability and functional outcomes following RSA. Multiple studies have recently investigated the incidence, risk factors, and treatment strategies for these injuries. In this article, the authors review current literature and discuss the incidence, cause, associated risk factors, treatment options, and outcomes following fractures of the acromion or scapular spine after RSA.
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http://dx.doi.org/10.1016/j.ocl.2021.03.006DOI Listing
July 2021

Early repair of traumatic rotator cuff tears improves functional outcomes.

J Shoulder Elbow Surg 2021 Mar 24. Epub 2021 Mar 24.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address:

Background: The impact of surgical timing on outcomes involving traumatic rotator cuff tears (RCTs) remains uncertain. The purpose of this study was to determine how functional outcomes are affected by surgical timing in traumatic RCTs.

Methods: We performed a retrospective review of patients with repair of traumatic full-thickness RCTs. Preoperative magnetic resonance imaging scans were evaluated by 2 blinded reviewers to measure RCT area and muscular atrophy. Functional outcomes were assessed via the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Simple Shoulder Test score, and visual analog scale (VAS) pain score. Patients were divided into 4 groups based on the time from injury to surgery: 0-2 months (group 1), 2-4 months (group 2), 4-6 months (group 3), and 6-12 months (group 4). Multivariate analysis was performed to assess the impact of surgical timing on functional outcomes. A subanalysis was performed to assess outcomes in patients who underwent surgery within 3 weeks of injury.

Results: The study included 206 patients (150 men and 56 women) with a mean age of 60.0 ± 9.7 years and a minimum of 24 months' clinical follow-up (mean, 35.5 months; range, 24-54.4 months). The average tear area was 8.4 ± 6.3 cm in group 1 (66 patients), 5.8 ± 5.1 cm in group 2 (76 patients), 5.1 ± 4.6 cm in group 3 (29 patients), and 3.7 ± 3.1 cm in group 4 (35 patients) (P < .001). There were significant differences between the 4 cohorts in the final postoperative ASES score (P = .030) and VAS pain score (P = .032). The multivariate regression demonstrated that patients who underwent surgery within 4 months of injury had estimated improvements of 10.3 points in the ASES score (P = .008), 1.8 points in the Simple Shoulder Test score (P = .001), 8.6 points in the SANE score (P = .033), and 0.93 points in the VAS pain score (P = .028) compared with patients who underwent surgery later. The subanalysis demonstrated that patients who underwent surgery within 3 weeks of injury (n = 13) had significantly better VAS (P = .003), ASES (P = .008), and SANE (P = .019) scores than patients who underwent surgery at between 3 weeks and 4 months after injury (n = 129).

Conclusions: This study demonstrates that surgical repair of traumatic RCTs results in significant improvements in functional outcomes for all patients; however, patients who undergo surgery within 3 weeks can expect the best functional outcomes, with a drop in function in patients who undergo surgery >4 months after injury.
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http://dx.doi.org/10.1016/j.jse.2021.03.134DOI Listing
March 2021

Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study.

J Shoulder Elbow Surg 2021 Mar 24. Epub 2021 Mar 24.

Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA. Electronic address:

Background: Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR).

Methods: Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery.

Results: A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05).

Conclusion: Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.
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http://dx.doi.org/10.1016/j.jse.2021.03.132DOI Listing
March 2021

Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component.

J Shoulder Elbow Surg 2021 Mar 19. Epub 2021 Mar 19.

Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.

Hypothesis: The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component.

Methods: Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation.

Results: Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment.

Conclusion: Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.
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http://dx.doi.org/10.1016/j.jse.2021.02.023DOI Listing
March 2021

A meta-analysis of level I evidence comparing tenotomy vs tenodesis in the management of long head of biceps pathology.

J Shoulder Elbow Surg 2021 May 16;30(5):961-968. Epub 2021 Feb 16.

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

Background: The ideal surgical treatment of long head of biceps pathology is unclear. This review evaluates Level I studies comparing tenotomy and tenodesis for the management of long head of biceps pathology.

Methods: Medline, EMBASE, and the Cochrane Library databases were searched from database inception though April 17, 2020. Clinical outcomes including Constant-Murley Shoulder Outcome Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) shoulder score, pain on visual analog scale, postoperative strength, and Popeye deformity were evaluated. Dichotomous outcomes were pooled into relative risk ratios whereas continuous outcomes were pooled into weighted mean differences using random effects meta-analysis.

Results: A total of 5 studies (227 tenotomy and 227 tenodesis patients) met the final inclusion criteria. Postoperative improvement across all outcomes was observed regardless of surgical treatment. Pooled analysis demonstrated no statistically significant difference for Constant-Murley Shoulder Outcome Score, ASES, pain, or flexion strength. Tenodesis was superior to tenotomy in reducing the risk of Popeye deformity (relative risk ratio 3.07, confidence interval 1.87, 5.02; P < .001).

Conclusion: Tenotomy and tenodesis of the long head of the biceps results in comparable postoperative clinical and functional outcomes. Tenodesis is superior to tenotomy in preventing Popeye deformity postoperatively.
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http://dx.doi.org/10.1016/j.jse.2021.02.002DOI Listing
May 2021

Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jul 22;30(7):1613-1618. Epub 2020 Oct 22.

Department of Orthopaedic Surgery, The Rothman Institute-Thomas Jefferson, Philadelphia, PA, USA. Electronic address:

Background: Venous thromboembolism (VTE) events are infrequent but potentially catastrophic complications following orthopedic surgery. There is currently a paucity of evidence regarding the role of chemoprophylaxis with low-dose aspirin (acetylsalicylic acid [ASA]) after shoulder arthroplasty.

Methods: We conducted a retrospective review of prospectively collected complications occurring within 90 days of 2394 primary shoulder arthroplasties performed over a 3-year period at a single institution. Patients preoperatively underwent risk stratification into medically high risk, moderate risk, or low risk as part of a standardized navigated-care pathway. For chemoprophylaxis, 81 mg of ASA (low dose) was routinely used once daily for 6 weeks unless alternative medications were deemed necessary by the medical team. Baseline demographic information, medical comorbidities, and postoperative VTE prophylaxis, as well as rates of clinically symptomatic VTE, were assessed.

Results: Symptomatic VTE occurred after 0.63% of primary shoulder arthroplasties (15 of 2394). There were 9 patients with deep vein thromboses and 6 with pulmonary embolisms. Eighty-one milligrams of ASA was used in 2141 patients (89.4%), resulting in an overall VTE rate of 0.56%. Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of deep vein thrombosis, asthma, and cardiac arrhythmia were significantly more likely to have a VTE (P < .05). Complications occurred in 4 patients (0.19%) associated with low-dose ASA and 1 patient (0.63%) associated with a novel oral anticoagulant medication.

Conclusion: Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE.
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http://dx.doi.org/10.1016/j.jse.2020.09.030DOI Listing
July 2021

Early clinical and radiographic outcomes of an augmented baseplate in reverse shoulder arthroplasty for glenohumeral arthritis with glenoid deformity.

J Shoulder Elbow Surg 2021 Jul 30;30(7S):S123-S130. Epub 2021 Jan 30.

Department of Orthopaedic Surgery, The Rothman Institute-Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Shoulder/Elbow Surgery, The Rothman Institute-Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address:

Background: Glenoid deformity is commonly encountered in patients undergoing reverse shoulder arthroplasty (RSA). Augmented baseplates can correct glenoid deformity while potentially avoiding certain complications encountered with structural bone graft. Limited evidence exists to support the use of metallic augmented baseplates in RSA.

Methods: We performed a retrospective review to identify all patients treated with an augmented baseplate during primary RSA with a minimum of 1 year of clinical and radiographic follow-up. Preoperative radiographs and advanced imaging were used to determine glenoid morphology and deformity. Postoperative radiographs were used to evaluate for deformity correction, radiographic complications, and early baseplate loosening or failure. Prospectively collected clinical data and patient-reported outcome scores were determined.

Results: Primary RSA was performed with an augmented baseplate in 44 patients (mean age, 72 ± 6 years; 15 half-wedge and 29 full-wedge augmentations). Glenoid retroversion was significantly improved for the entire cohort (P = .001). Among the 22 patients with either Walch type B2, B3, or C glenoid morphology, glenoid version improved from 28° ± 8° to 16° ± 8° (P = .001). Glenoid inclination, as determined by the β angle, was significantly improved for the entire cohort (P < .001). Among the 18 patients with Favard type E2 or E3 glenoid morphology, glenoid inclination improved from 67° ± 7° to 81° ± 8° (P < .001). Postoperative range of motion and functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numeric Evaluation score, and visual analog scale score for pain significantly improved within the entire cohort (P < .05). No patients had evidence of baseplate loosening or failure of the glenoid component. Acromial stress fractures developed in 5 patients (11.4%), and 2 patients (4.5%) underwent a reoperation unrelated to the glenoid component.

Discussion And Conclusion: Primary RSA with an augmented baseplate results in excellent short-term clinical outcomes and significant deformity correction in patients with advanced glenoid deformity. There were no complications related to the augmented baseplate or glenoid component. The rate of acromial stress fractures appears higher than typically reported and warrants further investigation.
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http://dx.doi.org/10.1016/j.jse.2020.12.010DOI Listing
July 2021

Performance in major league baseball pitchers after surgical treatment of thoracic outlet syndrome.

Phys Sportsmed 2021 Mar 21:1-6. Epub 2021 Mar 21.

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.

: Thoracic outlet syndrome (TOS) can be a career-threatening injury for Major League Baseball (MLB) pitchers, often requiring surgical management. The purpose of this study is to determine the efficacy of surgical management for TOS as a function of return to play and quantitative pitching metrics.: 27 MLB pitchers underwent surgical treatment for TOS between January 2001 and December 2017. Analysis of pre and postoperative pitching metrics were used to assess the effect of surgery on 20 pitchers who returned to pitch in MLB. All pitching metrics were compared via assessing performance two years prior to surgery and two years after surgery. For 20 pitchers who returned to pitch, MLB pitching metrics of earned run average (ERA), walks plus hits per innings pitched (WHIP), wins above replacement (WAR), and average fastball velocity were used to assess a pitcher's ability to return to preoperative performance level.: Of the 27 pitchers, 20 pitchers were diagnosed with neurogenic thoracic outlet syndrome (NTOS) and seven with venous thoracic outlet syndrome (VTOS). The average age of onset of TOS was 28.6 years. There was no significant difference between the age of onset between the NTOS and VTOS populations (p = 0.272). Of the 27 pitchers, 20 (74.1%) were able to return to MLB play at a mean of 297 days (range, 105-638 days) after surgery. Pitching metrics demonstrated that pitcher ERA remained inferior postoperatively compared to baseline preoperative performance (3.66 vs 4.50, p = 0.03). Fastball velocity (p = 0.94) and strike percentage (p = 0.50) were equivalent to pre-injury performance.: 74% of professional pitchers who undergo surgical intervention for TOS are able to return to play at the MLB level. With regards to performance, the majority of metrics were unchanged from prior to surgery, indicating return at a similar functional level.
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http://dx.doi.org/10.1080/00913847.2021.1880251DOI Listing
March 2021

The Basic Shoulder Arthroplasty: Simple Shoulder Replacement for the Generalist.

Instr Course Lect 2021 ;70:37-54

Shoulder arthroplasty was first introduced through the developments of Dr. Charles Neer and over the past decade has seen several advancements. Improved recognition and training have heightened the awareness of arthroplasty as a treatment alternative both for surgeons and patients. The addition of reverse shoulder arthroplasty has been the driving force behind the explosive growth of arthroplasty and is now performed more often than anatomic shoulder arthroplasty. Although revision shoulder arthroplasty is primarily of interest to the subspecialist, it is a skill sought by the general orthopaedic surgeon. It is important for the orthopaedic surgeon to be knowledgeable about the planning, necessary skills, and management of basic shoulder arthroplasty.
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January 2021

Clinical Outcomes and Quality of Literature Addressing Glenohumeral Internal Rotation Deficit: A Systematic Review.

HSS J 2020 Oct 17;16(3):233-241. Epub 2019 Jun 17.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI USA.

Background: Glenohumeral internal rotation deficit (GIRD) can negatively impact shoulder function particularly in the throwing athlete.

Questions/purpose: This study aimed to systematically evaluate recent trends in clinical outcomes and quality of published evidence pertaining to GIRD.

Methods: A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, MEDLINE, PubMed Central, and Embase were searched from January 1, 2011, through April 23, 2017, for all articles evaluating GIRD. Two reviewers independently screened articles for eligibility and extracted data for analysis.

Results: Eighty-two articles were included in the final review. In general, the overall number of articles published increased over time. Two-thirds of all studies were conducted in the USA. Seventy-eight percent ( = 64) of included studies were level-III to level-V evidence, with no level-I study performed during the study period. Eighty-five percent of studies were either epidemiologic, review, or imaging articles, and only 12% were clinical studies. Significant variability in the clinical definition of GIRD was identified. All studies evaluating non-operative management of GIRD demonstrated significant improvements in internal rotation of the affected extremity.

Conclusion: Current trends in GIRD-related literature demonstrate limited focus on clinical, therapeutic, or patient-reported outcomes and mostly consist of low-level evidence. There is a lack of consensus in the literature on what clinically constitutes GIRD.
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http://dx.doi.org/10.1007/s11420-019-09691-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534890PMC
October 2020

Modified L'Episcopo tendon transfer for isolated loss of active external rotation.

J Shoulder Elbow Surg 2020 Dec 9;29(12):2587-2594. Epub 2020 Jun 9.

Departments of Orthopaedic Surgery & Shoulder/Elbow Surgery, The Rothman Institute-Thomas Jefferson, Philadelphia, PA, USA.

Background: Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation.

Methods: A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up.

Results: Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%).

Conclusion: In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.
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http://dx.doi.org/10.1016/j.jse.2020.03.031DOI Listing
December 2020

Shoulder Hemiarthroplasty After Previous Pectoralis Major Transfer for Irreparable Subscapularis Tear: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0322

1Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Unité de l'épaule, Lyon, France 2Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 3MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.

Case: A 30-year-old woman with an irreparable subscapularis tear presented with persistent painful anterior instability despite several open and arthroscopic stabilization procedures. A pectoralis major tendon transfer (PMTT) was performed. The patient subsequently developed progressive glenohumeral arthritis over the next 10 years, ultimately necessitating shoulder arthroplasty.

Conclusions: PMTT provides valuable anterior soft-tissue reconstruction stabilization for subscapularis insufficiency in a multioperated shoulder. Ten years later, the transfer was found to be intact and managed like a native subscapularis during anatomic shoulder replacement, thus avoiding a reverse arthroplasty in a young patient.
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http://dx.doi.org/10.2106/JBJS.CC.19.00322DOI Listing
February 2021

Rehabilitation After Anatomic and Reverse Total Shoulder Arthroplasty: A Critical Analysis Review.

JBJS Rev 2020 02;8(2):e0129

Departments of Orthopaedic Surgery and Shoulder and Elbow Surgery, The Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania.

Postoperative rehabilitation is believed to be essential in optimizing clinical outcome and function following shoulder arthroplasty. Despite this long-held notion, there is a paucity of high-quality evidence to guide rehabilitation protocols and practice. For patients undergoing anatomic total shoulder arthroplasty (ATSA), there are insufficient comparative data regarding type or duration of sling utilization. Based on current evidence, there is no appreciable benefit to early motion compared with a delayed-motion protocol following ATSA. There is insufficient literature to support the use of formal physical therapy over a physician-directed program following ATSA. At the present time, no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty (RTSA). Prospective randomized controlled trials evaluating postoperative management and rehabilitation following ATSA and RTSA are needed to guide best practices and optimize clinical outcomes.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00129DOI Listing
February 2020

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under.

J Shoulder Elbow Surg 2019 Sep 13;28(9):1666-1673. Epub 2019 Jun 13.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

Background: Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy.

Methods: A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined.

Results: A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA.

Conclusion: In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.
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http://dx.doi.org/10.1016/j.jse.2019.03.006DOI Listing
September 2019

Current Workload Recommendations in Baseball Pitchers: A Systematic Review.

Am J Sports Med 2020 01 23;48(1):229-241. Epub 2019 Apr 23.

Department of Orthopedic Surgery, University of Michigan, Ypsilanti, Michigan, USA.

Background: Several recommendations have been made regarding pitch counts and workload for baseball players of different levels, including Little League, high school, collegiate, and professional baseball. However, little consensus is found in the literature regarding the scientific basis for many of these recommendations.

Purpose: The primary purpose of this study was to summarize the evidence regarding immediate and long-term musculoskeletal responses to increasing pitching workload in baseball pitchers of all levels. A secondary purpose of this review was to evaluate the extent to which workload influences injury and/or performance in baseball pitchers.

Study Design: Systematic review.

Methods: We performed a systematic search in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies addressing physiologic and/or pathologic musculoskeletal changes in response to a quantifiable pitching workload. We included studies examining the effects of pitching workload on performance, injury rate, and musculoskeletal changes in Little League, high school, collegiate, and professional baseball players.

Results: We identified 28 studies that met our inclusion and exclusion criteria: 16 studies regarding Little League and high school pitchers and 12 studies regarding collegiate and professional pitchers. The current evidence presented suggests that increased pitching workload may be associated with an increased risk of pain, injury, and arm fatigue in Little League and high school pitchers. However, little consensus was found in the literature regarding the association between pitching workload and physiologic or pathologic changes in collegiate and professional pitchers.

Conclusion: Evidence, although limited, suggests the use of pitch counts to decrease injury rates and pain in Little League and high school baseball pitchers. However, further research must be performed to determine the appropriate number of pitches (or throws) for players of different ages. This systematic review reported conflicting evidence regarding the use of pitch counts in college and professional baseball. Future high-quality research is required to determine the role, if any, of pitch counts for collegiate and professional pitchers.
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http://dx.doi.org/10.1177/0363546519831010DOI Listing
January 2020

Distal Clavicle Fractures: Open Reduction and Internal Fixation With a Hook Plate.

J Orthop Trauma 2018 Aug;32 Suppl 1:S2-S3

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI.

Displaced distal clavicle fractures pose unique challenges because of their propensity for instability. In particular, type II fracture patterns are associated with high rates of nonunion with nonoperative management; therefore, surgical fixation is often recommended. Hook plate fixation has demonstrated reliably high rates of osseous union with good functional outcomes. We present our surgical technique and rationale for using a hook plate in the setting of an unstable distal clavicle fracture.
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http://dx.doi.org/10.1097/BOT.0000000000001214DOI Listing
August 2018

Humeral Retroversion and Capsule Thickening in the Overhead Throwing Athlete: A Systematic Review.

Arthroscopy 2018 04 17;34(4):1308-1318. Epub 2018 Jan 17.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A.

Purpose: To investigate the humeral and soft-tissue adaptations, including humeral retroversion, range of motion, and posterior capsule changes, in overhead throwing athletes.

Methods: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase were searched from January 1, 2011, through April 23, 2017, by 2 reviewers independently and in duplicate. The methodologic quality of all included articles was assessed using the Methodological Index for Non-randomized Studies criteria. Interobserver agreement for assessments of eligibility was calculated with the Cohen κ statistic. Descriptive statistics and raw counts were used to summarize data.

Results: We identified 14 studies (6 Level IV and 8 Level III) including 1,152 overhead throwing athletes. The mean age of the included athletes was 18.37 years (standard deviation, 1.52 years), with 59% of the athletes being pitchers and 41% being position players. Significantly greater humeral retroversion was found across all studies evaluating bony morphology in the dominant arm of overhead throwing athletes (range of mean differences, 9.6°-25.8°). Each of these studies also found decreased internal rotation in the dominant arm (range of mean internal rotation differences, -28° to -7.8°). Five studies found a significant negative correlation between the difference in humeral retroversion between the 2 arms and the difference in internal rotation (range of Pearson correlation coefficients, -0.56 to -0.35). Soft-tissue adaptations were assessed in 5 studies, with 4 identifying significantly thicker posterior capsules and 2 identifying significantly stiffer posterior capsules (P < .05).

Conclusions: Overhead throwing athletes consistently show several distinct changes in their dominant shoulder. These include increased humeral retroversion and the presence of a thickened and stiff posterior capsule. Concomitantly, there is often reduced internal rotation and increased external rotation of the dominant arm.

Level Of Evidence: Level IV, systematic review of Level III and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2017.10.049DOI Listing
April 2018

Common Injuries in Professional Football Quarterbacks.

Curr Rev Musculoskelet Med 2018 03;11(1):6-11

MedSport, Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright, Lobby A, Suite 1000, Ann Arbor, MI, 48106, USA.

Purpose Of Review: Professional football quarterbacks are at particular risk for upper extremity injuries due to the physical demands of their position coupled with the inherent risks associated with professional football. This review sought to evaluate current clinical literature to better characterize the injury profile unique to this athletic population.

Recent Findings: Shoulder injuries are the most prevented upper extremity injury among professional football quarterbacks. The quarterback position is disproportionately impacted by shoulder injuries when compared to professional athletes at other positions. Moreover, contrary to other professional throwing athletes, the majority of upper extremity injuries in the professional quarterback result from direct contact as opposed to the throwing motion. The injury profile among professional quarterbacks is unique compared to other positions and other overhead professional throwing athletes. Overall, a paucity of high quality clinical evidence exists to support the management of injuries in this elite population.
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http://dx.doi.org/10.1007/s12178-018-9453-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825334PMC
March 2018

Platform shoulder arthroplasty: a systematic review.

J Shoulder Elbow Surg 2018 Apr 16;27(4):756-763. Epub 2017 Oct 16.

MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.

Background: Platform shoulder arthroplasty systems may allow conversion to a reverse total shoulder arthroplasty (RTSA) without removing a well-fixed, well-positioned humeral stem. We sought to evaluate the complications associated with humeral stem exchange versus retention in patients undergoing conversion shoulder arthroplasty with a platform shoulder arthroplasty system.

Methods: PubMed, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase were searched from database inception through October 9, 2016, for all articles comparing humeral stem retention versus exchange during conversion RTSA or that pertained to conversion RTSA with stem retention alone. All studies were screened in duplicate for eligibility. A methodologic quality assessment was completed for included studies. Pooled outcomes assessing complications, operative time, blood loss, and reoperations were determined.

Results: We included 7 studies (236 shoulders), including 1 level III and 6 level IV studies. Pooled analysis demonstrated significantly higher overall complications (odds ratio, 6.89; 95% confidence interval [CI], 2.48-19.13; P = .0002), fractures (odds ratio, 4.62; 95% CI, 1.14-18.67; P = .03), operative time (mean difference, 62.09 minutes; 95% CI, 51.17-73.01 minutes; P < .00001), and blood loss (mean difference, 260.06 mL; 95% CI, 165.30-354.83 mL; P < .00001) with humeral stem exchange. Stem exchange was also associated with increased risk of reoperation (P = .0437).

Conclusion: Conversion arthroplasty with retention of the humeral stem is associated with lower overall complications, blood loss, operative time, and reoperations in comparison with stem exchange.
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http://dx.doi.org/10.1016/j.jse.2017.08.020DOI Listing
April 2018

Tranexamic Acid in Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

JBJS Rev 2017 09;5(9):e3

1MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan 2Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada 3Beaumont Health System, Royal Oak, Michigan 4Krankenhaus der Barmherzigen Schwestern Wien Betriebsgesellschaft m.b.H, Vienna, Austria.

Background: The role of tranexamic acid (TXA) in reducing blood loss following primary shoulder arthroplasty has been demonstrated in small retrospective and controlled clinical trials. This study comprehensively evaluates current literature on the efficacy of TXA to reduce perioperative blood loss and transfusion requirements following shoulder arthroplasty.

Methods: PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through October 27, 2016, for all articles evaluating TXA in shoulder arthroplasty. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of the risk of bias and strength of evidence. The primary outcome was change in hemoglobin and the secondary outcomes were drain output, transfusion requirements, and complications. Pooled outcomes assessing changes in hemoglobin, drain output, and transfusion requirements were determined.

Results: Five articles (n = 629 patients), including 3 Level-I and 2 Level-III studies, were included. Pooled analysis demonstrated a significant reduction in hemoglobin change (mean difference [MD], -0.64 g/dL; 95% confidence interval [CI], -0.84 to -0.44 g/dL; p < 0.00001) and drain output (MD, -116.80 mL; 95% CI, -139.20 to -94.40 mL; p < 0.00001) with TXA compared with controls. TXA was associated with a point estimate of the treatment effect suggesting lower transfusion requirements (55% lower risk); however, the wide CI rendered this effect statistically nonsignificant (risk ratio, 0.45; 95% CI, 0.18 to 1.09; p = 0.08). Findings were robust with sensitivity analysis of pooled outcomes from only Level-I studies.

Conclusions: Moderate-strength evidence supports use of TXA for decreasing blood loss in primary shoulder arthroplasty. Further research is necessary to evaluate the efficacy of TXA in revision shoulder arthroplasty and to identify the optimal dosing and route of administration of TXA in shoulder arthroplasty.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.RVW.17.00021DOI Listing
September 2017

Age and dressing type as independent predictors of post-operative infection in patients with acute compartment syndrome of the lower leg.

Int Orthop 2017 12 20;41(12):2591-2596. Epub 2017 Jul 20.

Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA.

Purpose: The purpose of this study was to determine independent factors, including timing of fasciotomy, that confer an increased risk of post-operative surgical site infection (SSI) in patients presenting with acute compartment syndrome (ACS) of the lower extremity.

Methods: A retrospective analysis was performed on a consecutive cohort of 53 adult patients requiring fasciotomy for lower-extremity fractures complicated by ACS presenting to a single Level I trauma center over a seven-year study period. The primary outcome measure was the incidence of SSI (as defined by the CDC) occurring within 12 months of fasciotomy. Explanatory variables including site of ACS, time of injury, time of fasciotomy, operative findings, and requirement for additional soft tissue coverage procedures were recorded for all patients. Multivariate regression was used to determine independent predictors of post-operative SSI.

Results: post-operative SSI was detected in 16 (30.2%) patients. Compared to infection-free patients, patients with post-operative SSI had a significantly higher median age (52.0 vs. 37.0 years, p = 0.010), frequency of intra-operative myonecrosis at time of fasciotomy (31.2% vs. 5.4%, p = 0.021), and requirement for negative-pressure wound therapy [NPWT] (93.7% vs. 45.9%, p = 0.002). Multivariate logistic regression analysis confirmed that requirement for NPWT (odds ratio [OR], 17.10; 95% confidence interval [CI], 1.78-164.0; p = 0.014) and increasing age (OR, 1.07; 95% CI, 1.01-1.14; p = 0.037) were independent predictors of post-operative SSI. Timing of fasciotomy following injury was not independently related to the risk of SSI.

Conclusions: ACS occurs on a spectrum of disease severity that evolves variably over time. Increasing age of the patient and requirement for NPWT following fasciotomy are independent predictors of post-operative SSI following emergent fasciotomy for ACS. Further studies are required to inform optimal treatment strategies in such patients.

Level Of Evidence: Therapeutic, Level III.
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http://dx.doi.org/10.1007/s00264-017-3576-1DOI Listing
December 2017

Is There an Association Between the "Critical Shoulder Angle" and Clinical Outcome After Rotator Cuff Repair?

Orthop J Sports Med 2017 Apr 18;5(4):2325967117702126. Epub 2017 Apr 18.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background: Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCTs). The critical shoulder angle (CSA) accounts for both glenoid inclination and lateral extension of the acromion. The impact of the CSA on outcomes after rotator cuff repair (RCR) has not been investigated previously.

Hypothesis: Our hypothesis was that individuals with smaller CSAs will have better patient-reported outcome scores over time compared with those with larger CSAs. Theoretically, a smaller CSA minimizes the biomechanical forces favoring superior translation of the humeral head, which may be advantageous after RCR. This is the first study to examine the relationship between the CSA and clinical outcomes after RCR.

Study Design: Cohort study; Level of evidence, 2.

Methods: Fifty-three patients (mean age, 61 years) with atraumatic full-thickness RCTs who underwent arthroscopic RCR were prospectively evaluated. Demographic data as well as the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, and a visual analog scale (VAS) for pain were prospectively collected at various time points up to 24 months postoperatively. Statistical analysis included longitudinal multilevel regression modeling to investigate the association between the CSA and the WORC, ASES, and VAS scores.

Results: The overall clinical outcome, as measured by the WORC, ASES, and VAS, improved significantly ( < .0001). Controlling for demographic and clinical characteristics, a multilevel regression analysis demonstrated that the CSA was not a significant independent predictor for change in WORC ( = .581), ASES ( = .458), or VAS ( = .859) scores at 24 months after arthroscopic RCR. Interobserver and intraobserver reliability for CSA measurements resulted in interclass correlation coefficients of 0.986 and 0.982, respectively ( < .001), indicating excellent agreement.

Conclusion: The CSA did not appear to be a significant predictor of patient-reported outcomes after arthroscopic repair of atraumatic full-thickness RCTs.
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http://dx.doi.org/10.1177/2325967117702126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400133PMC
April 2017

Return to Play After Osteochondral Autograft Transplantation of the Capitellum: A Systematic Review.

Arthroscopy 2017 Jul 13;33(7):1412-1420.e1. Epub 2017 Apr 13.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A.

Purpose: To determine the rate of return to play and to identify lesion or osteochondral graft characteristics that may influence the return to competitive athletics after osteochondral autograft transplantation (OAT) for symptomatic osteochondritis dissecans (OCD) lesions.

Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A duplicate search of PubMed, Embase, Scopus, Web of Science, and CENTRAL databases was performed, beginning from the database inception dates through July 2016, for all articles evaluating the return to play after OAT for OCD lesions of the capitellum. A methodological quality assessment was completed for all included studies. Patient demographics, osteochondral lesion and graft characteristics, the number of patients, and timing of return to competitive activity were collected and evaluated. Association between graft size/number, the time to osseous healing, and return to sport was evaluated.

Results: Seven articles met the inclusion criteria. All included studies were case series of moderate quality with a mean Methodological Index for Non-Randomized Studies score of 12/16. Overall, 94% (119/126) of patients undergoing OAT for OCD lesions of the capitellum successfully returned to competitive sports. The mean reported time for unrestricted return to athletic competition after OAT was 5.6 months (range, 3-14 months).

Conclusions: Current best evidence suggests that OAT is successful in treating advanced OCD lesions of the capitellum and returning athletes to high-level competition. Evidence supporting the association between the size and number of grafts used and the time to osseous healing and return to sport is currently limited. Our assessment of the time to return to athletic competition was limited because of variable surgical technique, postoperative rehabilitation protocols, and outcome assessment.

Level Of Evidence: Level IV, systematic review of Level IV studies.
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http://dx.doi.org/10.1016/j.arthro.2017.01.046DOI Listing
July 2017

Does Hip Arthroscopy Have a Role in the Treatment of Developmental Hip Dysplasia?

J Arthroplasty 2017 09 27;32(9S):S28-S31. Epub 2017 Feb 27.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.

Background: Indications for hip arthroscopy in mildly dysplastic patients with a symptomatic hip remain controversial.

Methods: This article provides a concise review of the available literature evaluating the role of hip arthroscopy in treating symptomatic dysplasia. Potential indications for hip arthroscopy in isolation are reviewed. Emerging evidence on the role of hip arthroscopy based on patient-specific pathomorphology is highlighted.

Results: Hip arthroscopy in isolation may be helpful for select dysplastic patients with dynamic impingement or microinstability. Isolated arthroscopic treatment of intra-articular pathology resulting from static overload is unlikely to be successful in the long term and may be detrimental.

Conclusion: Arthroscopic procedures for individuals with mild dysplasia in the absence of frank instability may be effective; however, great caution should be exercised when approaching dysplastic patients with symptomatic hips.
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http://dx.doi.org/10.1016/j.arth.2017.02.022DOI Listing
September 2017

Current Concepts: Osteochondritis Dissecans of the Capitellum and the Role of Osteochondral Autograft Transplantation.

Hand (N Y) 2016 12 24;11(4):396-402. Epub 2016 Aug 24.

University of Michigan, Ann Arbor, USA.

Osteochondritis dissecans (OCD) of the capitellum is a painful condition, which often affects young throwing athletes. Our current understanding regarding the etiology, risks factors, diagnosis, and efficacy of the available treatment options has expanded over recent years, however remains suboptimal. Recent data on patient-reported outcomes following osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the capitellum have been promising but limited. This review seeks to critically analyze and summarize the available literature on the etiology, diagnosis, and reported outcomes associated with OCD of the capitellum and the use of OAT for its treatment. A comprehensive literature search was conducted. Unique and customized search strategies were formulated in PubMed, Embase, Scopus, Web of Science, and CENTRAL. Combinations of keywords and controlled vocabulary terms were utilized in order to cast a broad net. Relevant clinical, biomechanical, anatomic and imaging studies were reviewed along with recent review articles, and case series. Forty-three articles from our initial literature search were found to be relevant for this review. The majority of these articles were either review articles, clinical studies, anatomic or imaging studies or biomechanical studies. Current evidence suggests that OAT may lead to better and more consistent outcomes than previously described methods for treating large OCD lesions of the capitellum.
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http://dx.doi.org/10.1177/1558944716643293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256660PMC
December 2016

Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma.

Case Rep Orthop 2015 17;2015:921526. Epub 2015 Jun 17.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109, USA.

Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results.
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http://dx.doi.org/10.1155/2015/921526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488082PMC
July 2015

Aggressive tibial lesion in a 70-year-old man.

Clin Orthop Relat Res 2014 Aug 28;472(8):2555-60. Epub 2014 May 28.

The George Washington University of Medicine and Health Sciences, Washington, DC, USA.

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http://dx.doi.org/10.1007/s11999-014-3704-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079861PMC
August 2014
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