Publications by authors named "Josef K Eichinger"

64 Publications

Variability and Reliability of 2 Dimensional Versus 3 Dimensional Glenoid Version Measurements with 3 Dimensional Preoperative Planning Software.

J Shoulder Elbow Surg 2021 Aug 16. Epub 2021 Aug 16.

Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA. Electronic address:

Introduction: Preoperative planning for total shoulder arthroplasty (TSA) may change based on the measured degree of glenoid version. Both two-dimensional (2D) and three-dimensional (3D) computerized tomographic (CT) scans are used to measure glenoid version with no consensus on which method is most accurate. However, it is generally accepted that 3D measurements are more reliable, yet most 3D reconstruction software currently in clinical use has never been directly compared to 2D. The purpose of this study is to directly compare 2D and 3D glenoid version measurements and determine the differences between the two.

Methods: CT scans were performed preoperatively on 315 shoulders undergoing either anatomic or reverse TSA. 2D measurements of glenoid version were obtained manually using the Friedman method, while 3D measurements were obtained using the Equinoxe Planning Application (Exactech Inc, Gainesville, FL) 3D-reconstruction software. Negative version values indicate retroversion, while positive values indicate anteversion. Two observers collected the 2D measurements two separate times, and intra- and inter-observer measurements were calculated. Groups were compared for variability using Intraclass Correlation Coefficients (ICC), and for differences in sample means using student t-tests. Additionally, samples were stratified by version value in order to better understand the potential sources of error between measurement techniques.

Results: For the 2D measurements, intra-observer variability indicated excellent reproducibility for both Observer 1 (ICC = .928, 95% CI: .911-.942) and Observer 2 (ICC = .964, 95% CI: .955-.971). Inter-observer variability measurements also indicated excellent reproducibility (ICC = .915, 95% CI: .778-.956). The overall 2D version measurement average (-4.9° ± 10.3°) was significantly less retroverted than the 3D measurement average (-8.4° ± 9.1°), (P < .001), with 3D measurements yielding a more retroverted value 73% of the time. When stratified on the basis of version value with outliers excluded, there was no significant difference in the distribution of high-error samples within the data.

Discussion: There was excellent reproducibility between the two observers in terms of both intra- and inter-observer variability. The 3D measurement techniques were significantly more likely to return a more retroverted measurement, and high error samples were evenly distributed throughout the data, indicating that there were no discernable trends in the degree of error observed. Shoulder surgeons should be aware that different glenoid version measurement strategies can yield different version measurements, as these can affect preoperative planning and surgeon decision making.
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http://dx.doi.org/10.1016/j.jse.2021.07.011DOI Listing
August 2021

Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jul 20. Epub 2021 Jul 20.

Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA. Electronic address:

Background: Limited data exist regarding the clinical and functional outcomes following primary total shoulder arthroplasty in obese patients. The purpose of this study is to determine the effects of obesity on the clinical and functional outcomes following primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in a large patient population with mid-term follow-up.

Methods: Patients in a multi-institutional shoulder registry receiving either primary aTSA (n = 1520) or rTSA (n = 2054) from 2004 to 2018 with a minimum follow-up period of 2 years were studied. All patients received the same single-platform shoulder prosthesis. Study groups were assigned based on implant type (anatomic or reverse), and further stratification was based on patient body mass index (BMI), with obese patients having a BMI ≥ 30 and non-obese patients having a BMI < 30. Patients were evaluated and scored preoperatively and at latest follow-up by use of 5 scoring metrics and range of motion (ROM).

Results: The mean follow-up period was 5 years (range, 2-14 years). Obese patients comprised 41% of the aTSA group and 35% of the rTSA group. Significant postoperative improvements in visual analog scale pain scores, ROM, and all 5 scoring metrics occurred in both obese and non-obese patients (P < .05). Obese patients in both groups reported higher preoperative and postoperative visual analog scale pain scores and less preoperative and postoperative ROM compared with non-obese patients. Compared with non-obese patients, obese patients receiving aTSA reported significantly worse postoperative Simple Shoulder Test, Constant-Murley, American Shoulder and Elbow Surgeons, University of California, Los Angeles, and Shoulder Pain and Disability Index scores compared with non-obese patients, and those receiving rTSA reported significantly worse American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index scores (all P < .05). However, these differences did not exceed the minimal clinically important difference or substantial clinical benefit criteria. Radiographic analysis showed that in the rTSA group, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade compared with non-obese patients (P < .05).

Discussion: Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following both aTSA and rTSA. Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both aTSA and rTSA at a mean follow-up of 5 years. However, statistically significant differences were not found to be clinically significant with respect to established minimal clinically important difference and substantial clinical benefit criteria. Therefore, obese and non-obese patients experience similar clinical outcomes following total shoulder arthroplasty, regardless of BMI. However, obese patients have more comorbidities, greater intraoperative blood loss, and less scapular notching compared with non-obese patients.
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http://dx.doi.org/10.1016/j.jse.2021.06.011DOI Listing
July 2021

Biomechanical evaluation of an intramedullary clavicle screw in simple oblique and butterfly wedge fractures.

Proc Inst Mech Eng H 2021 Jul 21:9544119211031052. Epub 2021 Jul 21.

Medical College of Georgia at Augusta University, Augusta, GA, USA.

This biomechanical study evaluates the performance of a solid titanium-alloy intra-medullary () clavicular screw in torsion and cantilever bending in cadaveric clavicle specimens with simulated simple oblique and butterfly wedge midshaft fractures. Thirty-two fresh-frozen male clavicles were sorted into six experimental groups: Torsion Control, Torsion Simple Oblique Fracture, Torsion Butterfly Wedge Fracture, Bending Control, Bending Simple Oblique Fracture, and Bending Butterfly Wedge Fracture. The experimental groups were controlled for density, length, diameter, and laterality. All other samples were osteotomy-induced and implanted with a single 90 mm × 3 mm clavicle screw. All groups were tested to physiologically relevant cutoff points in torsion or bending. There were no statistically significant differences in the performance of the oblique and butterfly wedge fracture models for any torsion or bend testing measures, including maximum torsional resistance ( = 0.66), torsional stiffness ( = 0.51), maximum bending moment ( = 0.43), or bending stiffness ( = 0.73). Torsional testing of samples in the direction of thread tightening tended to be stronger than samples tested in loosening, with all groups either approaching or achieving statistical significance. There were no significant differences between the simple oblique or the butterfly-wedge fracture groups for any of the tested parameters, suggesting that there is no difference in the gross biomechanical properties of the bone-implant construct when the clavicle screw is used in either a simple midshaft fracture pattern or a more complex butterfly wedge fracture pattern.
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http://dx.doi.org/10.1177/09544119211031052DOI Listing
July 2021

Effects of the Obesity Epidemic on Total Hip and Knee Arthroplasty Demographics.

J Arthroplasty 2021 Sep 22;36(9):3097-3100. Epub 2021 Apr 22.

Department of Orthopaedics, Medical University of South Carolina, Charleston, SC.

Background: Higher body mass index (BMI) is a well-known risk factor for the development of hip and knee osteoarthritis and predicts total hip arthroplasty (THA) and total knee arthroplasty (TKA) at an earlier age. The purpose of this study is to document the nationwide trends in age and obesity in primary THA and TKA throughout the obesity epidemic.

Methods: A retrospective analysis of the National Inpatient Sample database was conducted on patients undergoing primary THA and TKA for primary OA between 2002 and 2017. Analysis of variance and chi-square tests were performed to examine changes in age and obesity percentage over time, respectively. Pearson correlations were used to assess the relationship between patient age, BMI, and year of surgery.

Results: A total of 688,371 THA and 1,556,651 TKA were identified over the sixteen-year period. Between 2002 and 2017, the proportion of obese patients increased for both THA (7.0% to 22.7%, P < .001) and TKA (10.7% to 30.4%, P < .001). Mean age significantly decreased for both THA (66.7 to 65.9 years, P < .001) and TKA (67.6 to 66.8 years; P < .001). Over time, BMI significantly increased (THA: r = 0.221 vs. TKA: r = 0.272) and patient age decreased (THA: r = -0.031 vs. TKA: r = -0.137) for both procedures (P < .001 for all).

Conclusion: THA and TKA patients have become younger and increasingly more obese throughout the obesity epidemic, as obesity rates have tripled over this time period. The current investigation is the first to demonstrate significant trends in both age and obesity in the THA and TKA populations on a national level.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.arth.2021.04.017DOI Listing
September 2021

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair.

J Shoulder Elbow Surg 2021 Sep 8;30(9):2048-2055. Epub 2021 Feb 8.

Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA. Electronic address:

Background: Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients.

Methods: The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis.

Results: Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1).

Conclusion: Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.
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http://dx.doi.org/10.1016/j.jse.2020.12.024DOI Listing
September 2021

Orthopaedic Application of Cryotherapy: A Comprehensive Review of the History, Basic Science, Methods, and Clinical Effectiveness.

JBJS Rev 2021 Jan 26;9(1):e20.00016. Epub 2021 Jan 26.

Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina.

»: Cold therapy, also known as cryotherapy, includes the use of bagged ice, ice packs, compressive cryotherapy devices, or whole-body cryotherapy chambers. Cryotherapy is commonly used in postoperative care for both arthroscopic and open orthopaedic procedures.

»: Cryotherapy is associated with an analgesic effect caused by microvasculature alterations that decrease the production of inflammatory mediators, decrease local edema, disrupt the overall inflammatory response, and reduce nerve conduction velocity.

»: Postoperative cryotherapy using bagged ice, ice packs, or continuous cryotherapy devices reduced visual analog scale pain scores and analgesic consumption in approximately half of research studies in which these outcomes were compared with no cryotherapy (11 [44%] of 25 studies on pain and 11 [48%] of 23 studies on opioids). However, an effect was less frequently reported for increasing range of motion (3 [19%] of 16) or decreasing swelling (2 [22%] of 9).

»: Continuous cryotherapy devices demonstrated the best outcome in orthopaedic patients after knee arthroscopy procedures, compared with all other procedures and body locations, in terms of showing a significant reduction in pain, swelling, and analgesic consumption and increase in range of motion, compared with bagged ice or ice packs.

»: There is no consensus as to whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with bagged ice or ice packs. However, complications from cryotherapy, including skin irritation, frostbite, perniosis, and peripheral nerve injuries, can be avoided through patient education and reducing the duration of application.

»: Future Level-I or II studies are needed to compare both the clinical and cost benefits of continuous cryotherapy devices to bagged ice or ice pack treatment before continuous cryotherapy devices can be recommended as a standard of care in orthopaedic surgery following injury or surgery.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00016DOI Listing
January 2021

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint.

Arthroscopy 2021 06 13;37(6):1711-1716. Epub 2021 Jan 13.

Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A.

Purpose: To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections.

Methods: Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated.

Results: All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87).

Conclusions: US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making.

Level Of Evidence: III, prospective cohort study, diagnosis.
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http://dx.doi.org/10.1016/j.arthro.2020.12.238DOI Listing
June 2021

Editorial Commentary: Look More Closely at those Coronal Magnetic Resonance Imaging Cuts Before Concluding a Rotator Cuff Tendon Tear Is Irreparable-Don't Let an L-Shaped Tear Fool You.

Arthroscopy 2020 11;36(11):2831

Modification of the Patte rotator cuff tear classification by using 2 coronal cuts to judge severity of retraction can help differentiate repairable from irreparable rotator cuff tears and allow for more accurate tear pattern identification.
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http://dx.doi.org/10.1016/j.arthro.2020.08.027DOI Listing
November 2020

Shoulder Position During Magnetic Resonance Arthrogram Significantly Affects Capsular Measurements.

Arthroscopy 2021 01 19;37(1):17-25. Epub 2020 Sep 19.

Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A.. Electronic address:

Purpose: To determine whether change in shoulder position between internal rotation (IR) and external rotation (ER) during magnetic resonance arthrography (MRA) affects previously defined capsular measurements and to determine the utility of rotation in the diagnosis of instability.

Methods: A retrospective study was conducted of patients who received a shoulder MRA with humeral IR and ER views. Patients with an arthroscopically confirmed diagnosis of instability and those with clinically stable shoulders, no history of instability, and no MRA findings of instability were identified and compared. Humeral rotation, glenoid retroversion, humeral head subluxation, capsular length, and capsular area using axial sequences of IR and ER views were recorded. Analysis compared IR, ER, and Δ capsular measurements between groups using independent t tests and univariate and multivariate regression.

Results: Thirty-one subjects who were diagnosed with instability were included, along with 28 control subjects. Capsular length, capsular area, and humeral subluxations were significantly greater with ER compared with IR views (P < .001, P < .001, P < .001). Patients with instability displayed greater ER capsular length (P = .0006) and ER capsular area (P = .005) relative to controls. Multivariate logistic regression identified age, weight, sex, ER capsular length, and retroversion to be significant predictors of instability. ER capsular length independently predicts instability with 86% sensitivity and 84% specificity. Interobserver reliability using the intraclass correlation coefficient was rated good or excellent on all measurements.

Conclusion: Variance in humeral rotation during shoulder MRA significantly affects capsular measurements. Rotational views increase the utility of capsular measurements when assessing for instability, particularly capsular length and capsular area. The implementation of ER positioning enhances the ability to examine capsular changes of the shoulder joint and can assist in the diagnosis of instability.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2020.09.014DOI Listing
January 2021

Shoulder motion decreases as body mass increases in patients with asymptomatic shoulders.

JSES Int 2020 Sep 27;4(3):438-442. Epub 2020 Jun 27.

Medical University of South Carolina, Charleston, SC, USA.

Background: Higher complication rates are reported after shoulder arthroplasty in obese patients. Understanding the effect of body mass index (BMI) on range of motion (ROM) in asymptomatic shoulders may be useful in evaluating clinical outcomes for patients of varying BMIs presenting with shoulder pathology. The purpose of this study is to investigate patient characteristics, in particular BMI, that may affect ROM outcomes after shoulder arthroplasty.

Methods: Individuals aged 18 years or older (mean 57.21 ± 16.27 years) were recruited with asymptomatic shoulder presentation and without history of shoulder injury. A total of 224 shoulders were grouped into 4 BMI categories, and ROM was measured with a goniometer. Analysis was performed between patient demographics and ROM.

Results: Analyzed continuously, BMI negatively correlated with ROM for internal rotation (IR;  = -0.511, < .01), forward elevation (FE;  = -0.418, < .01), and external rotation (ER;  = -0.328, < .01). ROM analyzed by BMI category revealed a dose effect of BMI vs ROM. Obese patients demonstrated a significant decrease in IR whereas morbidly obese patients had significant decreases for all ranges: IR ( = -0.469, < .01), FE ( = -0.452, < .01), and ER ( = -0.33, < .01). Normal- and overweight patients revealed no significant correlations with ROM.

Conclusion: As BMI is negatively correlated with ROM of the asymptomatic shoulder, patients with higher BMIs may be predisposed to diminished outcomes postoperatively. These baseline correlations will allow surgeons to make postoperative expectations and anticipate poorer outcomes of shoulder ROM in obese patients.
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http://dx.doi.org/10.1016/j.jseint.2020.04.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479022PMC
September 2020

The effect of body mass index on internal rotation and function following anatomic and reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Feb 30;30(2):265-272. Epub 2020 Jun 30.

Medical University of South Carolina, Department of Orthopaedics, Charleston, SC, USA.

Background: The exact relationship between body mass index (BMI) and internal rotation (IR) before and after total shoulder arthroplasty has not been studied to date. The purpose of this study was to determine the effects of BMI on the preoperative and postoperative shoulder range of motion and function in anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA), and specifically how IR affects patient ability to perform IR-related activities of daily living (ADLs).

Methods: Patients from a prospective multicenter international shoulder arthroplasty registry who underwent primary rTSA (n=1171) and primary aTSA (n=883) were scored preoperatively and at latest follow-up (2-10 years, mean = 3 years) using the Simple Shoulder Test, University of California-Los Angeles shoulder score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Constant score, and Shoulder Pain and Disability Index patient-reported outcome measures (PROMs). Measured active abduction, forward flexion, IR, and active and passive external rotation were recorded, and BMI was evaluated as a predictor of motion and patient-reported outcomes. Patient responses to questions regarding the difficulty level of IR-related ADLs were studied. The relationships between BMI, IR, and ability to perform IR-related ADLs were quantified through analysis of variance with post hoc comparisons by Tukey honestly significant difference tests, where significance was denoted as P < .05.

Results: BMI was found to be inversely correlated with IR in patients undergoing both aTSA and rTSA, both preoperatively (P < .001 and P = .002) and postoperatively (P < .001 and P < .001). BMI affected the range of motion parameters of forward flexion abduction and external rotation but to a lesser extent than that of IR. Nonobese patients demonstrated significantly greater IR than overweight, obese, and morbidly obese patients postoperatively for aTSA (P < .001). For rTSA, nonobese patients had a significantly greater postoperative IR than obese and morbidly obese patients (P < .001 and P = .011, respectively). For both aTSA and rTSA patients, mean IR scores significantly differed between patients reporting normal function vs. patients reporting slight difficulty, considerable difficulty, or inability to perform IR-related ADLs. Increasing IR demonstrated a significant, positive correlation with all PROMs for both aTSA and rTSA patients (Pearson correlation, P < .001).

Conclusions: BMI is an independent predictor of IR, even when controlling for age, gender, glenosphere size, and subscapularis repair. BMI was inversely correlated with the degree of IR, and decreased IR significantly negatively affected the ability to perform IR-related ADLs.

Clinical Relevance: Increasing BMI adversely affects shoulder ROM, particularly IR. IR is correlated with the ability to perform ADLs requiring IR in both aTSA and rTSA patients.
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http://dx.doi.org/10.1016/j.jse.2020.06.008DOI Listing
February 2021

Intraoperative Identification of Clavicle Fracture Patterns: Do Clavicles Fail in a Predictable Pattern?

J Orthop Trauma 2020 12;34(12):675-678

Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC.

Objectives: To characterize the fracture pattern and pattern of fragmentation for displaced, midshaft clavicle fractures undergoing operative management.

Design: Prospective observational study.

Setting: Two institutions. Level 1 and Level 2 Trauma Centers.

Patients/participants: Fifty-three patients who underwent operative repair of midshaft clavicle fracture.

Intervention: All clavicles were treated by operative open reduction internal fixation.

Main Outcome Measurements: All clavicles were categorized by the Robinson classification based on injury plain film bilateral upright clavicle radiographs. In addition, intraoperative fracture characteristics of fragment length and location were measured and recorded to evaluate the fracture pattern. All fractures were analyzed to determine the frequency of segmental comminution versus length-stable patterns, analyze characteristics of butterfly fragment size, number and location as well as the location of the cortical read for those length-stable fractures.

Results: Analysis revealed 55% were Robinson 2B2 based on preoperative radiographs. Length-stable, anatomic reduction was achievable in 83%. For those in which an anatomic cortical read was achievable, 97.7% had a read present in the posterior-superior aspect of the clavicle.

Conclusions: Midshaft clavicle fractures that meet conventional criteria for operative repair occur in a predictable manner with butterfly fragments generated from anterior-inferior compression and simple fracture line generated from tension along the posterior-superior aspect of the clavicle. Understanding this pattern can assist in the in surgical planning.
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http://dx.doi.org/10.1097/BOT.0000000000001801DOI Listing
December 2020

Sex differences in complications and readmission rates following shoulder arthroplasty in the United States.

JSES Int 2020 Mar 29;4(1):95-99. Epub 2020 Feb 29.

Boston University School of Medicine, Boston, MA, USA.

Introduction: Shoulder arthroplasty (SA) procedures are increasingly performed in the United States. However, there is a lack of data evaluating how patient sex may affect perioperative complications. The purpose of this study was to evaluate sex-based differences in 30-day postoperative complication and readmission rates after SA.

Methods: Total SA and reverse SA cases between 2012-2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. The 30-day complication rate, readmission rate, operation time, length of stay, and mortality were compared between women and men. Multivariable logistic regression analysis was performed to identify independent perioperative complications associated with patient sex.

Results: Of 12,530 SA cases, 6949 (55.4%) were female and 5499 (44.5%) were male. Compared with women, on average men were significantly younger, had lower body mass index, and were less likely to be functionally dependent, and less likely to have an American Society of Anesthesiologists score of 3+ ( < .001). Although overall complications and readmission rates between women and men were similar (3.4% vs. 3.7%,  = .489; 3.0% vs. 2.8%,  = .497), men were significantly less likely to develop urinary tract infections (UTIs; odds ratio [OR] 0.58,  = .032) and require transfusions (OR 0.49, < .001) and had shorter lengths of stay ( < .001). However, men were significantly more likely to have a superficial surgical site infection (OR 2.63,  = .035) and 6.8 minute longer operating time ( < .001) compared with women.

Conclusion: Though the overall complication risk is similar between the sexes, their risk profiles are distinct. Men had decreased risk of UTI, blood transfusions, and shorter length of stay but increased risk of surgical site and longer operating time compared with women. This disparity should be discussed when counseling and risk-stratifying patients for SA.
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http://dx.doi.org/10.1016/j.jseint.2019.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075761PMC
March 2020

Pitch count adherence and injury assessment of youth baseball in South Carolina.

J Orthop 2020 Sep-Oct;21:62-68. Epub 2020 Feb 5.

Medical University of South Carolina, Department of Orthopaedic Surgery and Physical Rehabilitation, Department of Pediatrics, USA.

Introduction: Overuse injury in youth overhead athletes remains a concern. The introduction of pitch count guidelines was designed to limit the number of pitches per game. South Carolina is considered a warm weather climate which has been proven to expose overhead athletes to higher risk for injury. The purpose of this study was to detect baseline rates of arm pain and sequelae (injury, surgery, impact on participation) among southern youth baseball/softball players to better counsel players, parents, coaches and league administration on the prevention of arm injury.

Methods: A survey was distributed to 14 pediatric practices within the South Carolina Pediatric Practice Research Network. The 2-page survey included 28 closed-ended and descriptive questions that investigated physical and psychosocial responses during and after play. Additional questions were conducted on adherence and understanding of USA Baseball guidelines and pitch counting behavior.

Results: Two hundred and seventy three surveys were completed by parents of baseball/softball players. The players' average age was 11.6 years, who played on an average of 1.78 teams/leagues for 5.2 months each year. Only 26% of baseball players answered "Sometimes", "Often" or "Always" to their arm hurting. Arm fatigue, older age, parent/coach frustration with play, and months played were statistically significantly associated with arm pain. The survey revealed 58.9% of families were familiar with pitch count guidelines.

Discussion: Arm pain is relatively prevalent among the South Carolina youth baseball community and worse in older players and experience fatigue. This survey found lower percentage of youth overhead athletes experiencing arm discomfort when compared to prior studies. It is important for warm weather climate athletes to abide by guidelines, as they are more susceptible to arm injury. Increased recognition, education and compliance with pitch count guidelines will help protect these youth athletes from overuse injury.

Level Of Evidence: IV, Descriptive Epidemiology Study.
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http://dx.doi.org/10.1016/j.jor.2020.01.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036446PMC
February 2020

The Effect of Screw Design and Cortical Augmentation on Insertional Torque and Compression in Coracoid-Glenoid Fixation in a Sawbones Model.

Arthroscopy 2020 03 31;36(3):689-695. Epub 2019 Dec 31.

Medical University of South Carolina, Charleston, South Carolina. Electronic address:

Purpose: To compare screw insertional torque and coracoid-glenoid compression from 4 fixation techniques with different screw design parameters and cortical augmentation for the Latarjet procedure.

Methods: Simulated Latarjet procedures were performed with 4 fixation techniques using laminated polyurethane blocks with dimensions similar to the coracoid-glenoid construct. The groups included DePuy Synthes Mitek 3.5-mm partially threaded screws with top hats, Arthrex 3.75-mm fully threaded screws with a 2-hole plate, Arthrex 3.75-mm fully threaded screws, and Smith & Nephew 4.0-mm partially threaded screws. Screws were inserted using a digital torque-measuring screwdriver to determine maximum insertional torque. Pressure-sensitive film was used to measure the maximum contact pressure and the effective pressure distribution (EPD) between the coracoid and glenoid; the EPD represents the percentage of the film's surface area that experienced pressure greater than 10 MPa. One-way analysis of variance and post hoc tests were used for statistical analysis.

Results: Significant differences were found between the 4 fixation groups for each variable measured. The 2 cortically augmented systems produced significantly higher maximum insertional torque than the non-cortically augmented systems (P < .001 for both). The 3.75-mm screws with a 2-hole plate yielded significantly higher contact pressures than the 4.0-mm screws (P = .028). This group also had a high EPD, with a mean value more than double the values of the non-cortically augmented systems (P = .037 and P < .001).

Conclusions: Cortically augmented fixation methods showed higher maximum insertional torque, maximum contact pressure, and EPD between the surfaces of the coracoid and glenoid in this Sawbones model.

Clinical Relevance: Various implants are available for the Latarjet procedure, but their biomechanical characteristics have not yet been fully elucidated. Graft fracture and nonunion represent 2 modes of failure that may be related to insertional torque and coracoid-glenoid compression. This study compared screw insertional torque and compression achieved using 4 fixation techniques with different screw design parameters and cortical augmentation in a Sawbones model.
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http://dx.doi.org/10.1016/j.arthro.2019.10.011DOI Listing
March 2020

Analysis of glenohumeral joint intraarticular pressure measurements in volume-limited MR arthrograms in patients with shoulder-instability compared to a control group.

J Orthop 2020 Jan-Feb;17:63-68. Epub 2019 Aug 13.

Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA.

Purpose: Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder instability after a volume-limited arthrogram.

Materials And Methods: Patients aged 18-45 years with shoulder instability or pain were included. After injecting 10 cc of contrast-mixture, intraarticular pressure was recorded using an arterial-line pressure-transducer connected to a portable monitor.

Results: 14/16 (86%) patients were included - 7/14 (50%) had instability. Post-injection pressure measurement averaged 59.9 ± 44.0 mmHg (range 15-181). Instability patients averaged 60.8 ± 37.6 (range 15-117) versus 41.9 ± 14.0 mmHg (range 30-64) for non-instability (p > 0.1).

Conclusion: Glenohumeral pressure measurements are variable when utilizing standardized volume-limited arthrograms.
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http://dx.doi.org/10.1016/j.jor.2019.08.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919372PMC
August 2019

Magnetic Resonance Imaging Correlates With Computed Tomography for Glenoid Version Calculation Despite Lack of Visibility of Medial Scapula.

Arthroscopy 2020 01;36(1):99-105

Steadmon Phillipon Research Institute, Vail, Colorado, U.S.A.

Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) in the presence of varying amounts of the medial scapula body as compared with the gold standard of glenoid version measured on computed tomography (CT) imaging, including the entire scapula in a cohort of young patients with shoulder instability and without glenohumeral arthritis.

Methods: A retrospective review was performed on instability patients with preoperative MRI and CT imaging. Measurements of available scapular width and glenoid version were performed using the Cobb angle method to measure the angle between the plane of the glenoid fossa to Friedman's line on axial images. Intra- and interrater reliability analysis was performed using intraclass correlation coefficients to assess agreement between MRI and CT measurements. Paired t tests were used to compare measurement differences between MRI and CT.

Results: Thirty-two patients with both MRI and CT scans were assessed. Intra- and inter-rater assessment revealed strong agreement for scapular width measurement. For glenoid version measurement, intra-rater agreement was excellent and inter-rater agreement was moderate on CT and good on MRI. The mean available scapular body width was 24.7 mm longer on CT as compared with MRI (95% confidence interval 17.5-31.9, P < .0001; 109.8 ± 8.2 mm vs 85.1 ± 16.9 mm, respectively), with MRI having an average of 78.2% (±17.6%) of the CT scapular width shown on CT. No significant difference in glenoid version was found between MRI and CT (95% confidence interval -0.87 to 1.75, P = .499; MRI -2.57° vs CT -2.13°).

Conclusion: MRI provided significantly shorter available scapular widths when compared with CT imaging in a cohort of patients with glenohumeral instability and without arthritis. However, this failed to produce a significant difference of ≥5° in measured glenoid version compared with CT measurements when 75% (8 cm) of the scapular width was present on MRI. Measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field.

Level Of Evidence: Level III; study of diagnostic test.
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http://dx.doi.org/10.1016/j.arthro.2019.07.030DOI Listing
January 2020

Demographics and Distal Tibial Dimensions of Suitable Distal Tibial Allografts for Glenoid Reconstruction.

Arthroscopy 2019 10 13;35(10):2788-2794. Epub 2019 Sep 13.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Purpose: To evaluate whether characteristics such as age, height, weight, sex, or body mass index affected the distal tibial dimensions and radius of curvature (ROC) of a potential donor for anterior glenoid augmentation.

Methods: A retrospective review of magnetic resonance imaging of ankles without bony trauma was performed, and the anteroposterior (AP) and medial-lateral (ML) distances and ROC of the tibial plafond articular surface were measured. Demographic characteristics, including age, sex, height, weight, and body mass index, were recorded.

Results: A total of 141 imaging studies were included (73 men and 68 women; average age, 38.2 ± 12.65 years). All potential specimens accommodated harvest of a 10 × 22-mm distal tibial allograft bone block. Men had greater ML (42.74 cm [95% confidence interval (CI), 42.09-43.39 cm] vs 38.01 cm [95% CI, 37.30-38.72 cm]; P < .001) and AP (38.16 cm [95% CI, 37.47-38.85 cm] vs 34.57 cm [95% CI, 33.97-35.17 cm]; P < .001) dimensions. Significant moderately positive correlations were found for AP dimensions with height (r = 0.584, P < .001) and weight (r = 0.383, P < .001) and for ML dimensions with height (r = 0.711, P < .001) and weight (r = 0.467, P < .001). ROC was positively correlated with height (r = 0.509, P < .001) and weight (r = 0.294, P < .001). Patient age was not related to either the AP or ML distal tibial dimensions or ROC.

Conclusions: After magnetic resonance imaging analysis, all potential donors permitted harvest of a standard-sized distal tibial allograft irrespective of sex or common anthropometric measures, and 85.8% showed distal tibial morphology acceptable for glenoid augmentation. AP and ML graft dimensions and ROC correlated significantly with height and weight.

Level Of Evidence: Level II, diagnostic study.
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http://dx.doi.org/10.1016/j.arthro.2019.05.019DOI Listing
October 2019

Reverse shoulder arthroplasty has higher perioperative implant complications and transfusion rates than total shoulder arthroplasty.

JSES Open Access 2019 Jul 14;3(2):108-112. Epub 2019 Jun 14.

Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA.

Background: Indications for reverse total shoulder arthroplasty (RTSA) have expanded. The purpose of this retrospective cohort study was to evaluate national trends in shoulder arthroplasty utilization and to compare national perioperative complication rates for hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and RTSA in a matched cohort.

Methods: The National Inpatient Sample was queried from 2011-2013 to identify patients who underwent HA, TSA, or RTSA. Age, sex, race, insurance type, Elixhauser comorbidity index, and perioperative complications were identified. A coarsened exact matching algorithm was used to match RTSA patients with TSA and HA patients to compare medical and implant-related perioperative in-hospital complications. Multivariable logistic regression analysis was performed on unmatched data to identify risk factors for development of perioperative complications.

Results: Overall, 42,832 shoulder arthroplasties were identified (44% TSAs, 34% RTSAs, 19% HAs). After matching, RTSAs had 6.2 times the odds of a perioperative implant-related complication ( < .001) and 2 times the odds of a red blood cell transfusion compared with TSAs ( < .001). The logistic regression model showed that prior shoulder arthroplasty (odds ratio [OR], 15.1; < .001), younger age (OR, 0.98;  = .006), earlier year of index surgery (OR, 0.83;  = .002), history of illicit drug use (OR, 6.2;  = .008), and depression (OR, 2.3;  = .003) were risk factors for development of in-hospital implant-related complications after RTSA.

Conclusion: The perioperative implant-related complication rate and postoperative transfusion rate of RTSAs were significantly higher than those of TSAs. In addition, prior shoulder surgery, younger age, earlier year of index surgery, history of illicit drug use, and depression were risk factors for implant-related complications after RTSA. However, the perioperative RTSA implant-related complications did decline each year, suggesting a growing national proficiency with performing RTSA.
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http://dx.doi.org/10.1016/j.jses.2019.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620200PMC
July 2019

All-Polyethylene versus Metal-Backed Tibial Components in Total Knee Arthroplasty.

J Knee Surg 2019 Aug 8;32(8):714-718. Epub 2019 Apr 8.

Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina.

All-polyethylene tibial (APT) implants were incorporated into the initial design of the first total knee arthroplasty (TKA) systems. Since then, a dynamic shift has taken place and metal-backed tibial (MBT) implants have become the gold standard in TKA. This has mostly been due to the theoretical advantages of intraoperative flexibility and improved biomechanics in addition to the heavy influence of device manufacturers. MBT implant comes not only with a higher cost but also with potential for complications such as osteolysis, backside wear, and thinning of the polyethylene insert, which were not previously seen with APT implant. The majority of studies comparing APT and MBT implants have shown no difference in clinical outcomes and survivorship. Newer studies from the past decade have begun highlighting the economic advantages of APT implant, especially in patients undergoing primary, uncomplicated TKA. Use of APT implants in younger patients and those with a body mass index > 35 has not been extensively studied, but the existing literature suggests the use of APT implant in these cohorts to be equally as acceptable. With modern implant design and instrumentation, rising utilization of TKA along with current and future economic strain on health care, the increased use of APT implant could result in massive savings without sacrificing positive patient outcomes.
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http://dx.doi.org/10.1055/s-0039-1683979DOI Listing
August 2019

Racial and sex disparities in utilization rates for shoulder arthroplasty in the United States disparities in shoulder arthroplasty.

J Orthop 2019 May-Jun;16(3):195-200. Epub 2019 Feb 28.

Medical University of South Carolina, USA.

Purpose: To investigate racial disparities in shoulder arthroplasty (SA), accounting for demographic factors such as sex and age.

Methods: Data for SAs (2011-2014) was queried from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Population-adjusted SA utilization rates, racial and sex differences by age, length of stay, insurer, and comorbidities were calculated.

Results: Caucasians aged 45-64 are 54% more likely than African-Americans and 74% than Hispanics to receive surgery. For patients aged 65-84, the disparity is wider for African-Americans and narrower for Hispanics.

Conclusions: Policymakers and physicians should focus on further national efforts to alleviate healthcare disparities.
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http://dx.doi.org/10.1016/j.jor.2019.02.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411623PMC
February 2019

The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Orthopedics 2019 Mar 27;42(2):95-102. Epub 2019 Feb 27.

There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].
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http://dx.doi.org/10.3928/01477447-20190221-01DOI Listing
March 2019

Editorial Commentary: Treating Irreparable Rotator Cuff Tears With a Patch or Balloon: Is It All a Bunch of Hot Air?

Arthroscopy 2019 02;35(2):390-391

Both superior capsular reconstruction and a biodegradable balloon spacer function to limit proximal migration and restore glenohumeral joint forces similar to the intact rotator cuff in a cadaveric rotator cuff-deficient model. Although both the superior capsular reconstruction and biodegradable balloon spacer represent promising alternatives, additional clinical outcome data are needed to determine their role in the treatment of the massive, irreparable rotator cuff tear.
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http://dx.doi.org/10.1016/j.arthro.2018.11.030DOI Listing
February 2019

A Guide to Understanding Reimbursement and Value-Based Care in the Military Health System.

Mil Med 2019 03;184(3-4):e205-e210

Bureau of Medicine and Surgery, U.S. Navy, 7700 Arlington Blvd Falls Church, VA.

Introduction: With the continued rise in the cost of U.S. health care, there is an increased emphasis on value-based care methodologies. Value is defined as health outcomes achieved per dollar spent. Few studies have evaluated the role of value-based care in the Military Health System (MHS), especially in a format which physicians and providers can understand. The purpose of this article is to provide a guide to understanding current reimbursement systems and value-based care in the MHS and discuss potential strategies for improving value and military readiness.

Materials And Methods: We outlined the current value-based care methodologies in the MHS, and by using musculoskeletal care as an example, offer strategies for further improvement.

Results: The MHS has been a leader in the health care industry in adopting value-based care strategies. Current value-based systems in the MHS are primarily designed to incentivize process measure compliance. Initial steps toward measurement and reporting health outcomes have been made, however, with the military's use of the Integrated Resourcing and Incentive System (IRIS), National Surgical Quality Improvement Program (NSQIP) database, and the Joint Outpatient Experience Survey (JOES).

Conclusion: As this article will describe, universal reporting of health outcomes, adoption of integrated practice units, and a focus on determining outcomes of illness over the entire care cycle offer a significant opportunity to accelerate the MHS journey to providing true value-based care. The universal measurement and systematic improvement of outcomes based on this measurement will contribute to military medical readiness and warfighter effectiveness.
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http://dx.doi.org/10.1093/milmed/usy206DOI Listing
March 2019

Relationship Between the Critical Shoulder Angle and Shoulder Disease.

JBJS Rev 2018 Aug;6(8):e1

Medical University of South Carolina, Charleston, South Carolina.

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http://dx.doi.org/10.2106/JBJS.RVW.17.00161DOI Listing
August 2018

Editorial Commentary: The Subscapularis Is King, Ignore It at Your Peril.

Arthroscopy 2018 06;34(6):1785

As a variety of new techniques evolve for the young patient with an irreparable rotator cuff tear involving the supraspinatus and infraspinatus, we must not forget the lessons from Christian Gerber who pioneered the latissimus dorsi transfer as an effective treatment for adult irreparable rotator cuff tears. An intact subscapularis is vital to achieving a good result no matter if one considers a lat transfer, a lower trapezius transfer, a partial posterior rotator cuff tear, or a superior capsular release. Careful evaluation of this tendon and its function remains an important preoperative consideration.
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http://dx.doi.org/10.1016/j.arthro.2018.02.028DOI Listing
June 2018

Minimizing Blood Loss and Transfusions in Total Knee Arthroplasty.

J Knee Surg 2018 Aug 4;31(7):594-599. Epub 2018 May 4.

Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina.

Blood loss management is critical to positive outcomes in patients undergoing total knee arthroplasty (TKA). Transfusions are associated with an increased risk of major and minor adverse events, length of hospitalization, and overall cost associated with surgery. Many techniques have been investigated and compared. Tranexamic acid (TXA), an antifibrinolytic drug widely known to reduce blood loss, may be a bridge to the goal of eliminating blood transfusions from TKA. Administration of TXA can be performed intravenously, topically at the knee joint, orally, or in combination. A single bolus or multiple doses have reduced total blood loss and transfusion rates consistently, safely, and cost-effectively. The uptake in use of TXA by surgeons has been slow due to concerns in patients deemed high risk for thromboembolic events. Newer evidence from studies specifically involving high-risk patients demonstrates that TXA is indeed safe in this cohort and provides benefits that greatly outweigh potential risks. Incorporation of TXA as a routine part of TKA is in the best interest of patients, health care teams, and medical institutions. TXA can be employed seamlessly with other blood saving techniques and has the capacity to increase productivity and decrease overall cost. This can be achieved by reducing the incidence of transfusion and length of stay, and the need for practices such as preoperative anemia treatment and suction drainage.
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http://dx.doi.org/10.1055/s-0038-1648223DOI Listing
August 2018

Current Trends in the Use of Shoulder Arthroplasty in the United States.

Orthopedics 2018 May 16;41(3):e416-e423. Epub 2018 Apr 16.

Reverse total shoulder arthroplasty (rTSA) has become increasingly popular since its introduction to the United States. The purpose of this study was to assess the current trends and use of rTSA, anatomic total shoulder arthroplasty (aTSA), and hemiarthroplasty (HA) from 2011 to 2014. Shoulder arthroplasty data from the National (Nationwide) Inpatient Sample database were analyzed for the years 2011 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. For each procedure, use and patient and hospital characteristics were identified. Shoulder arthroplasties increased by 24% between 2011 and 2014, to 79,105 procedures. The proportion of arthroplasties that were aTSA did not change substantially (44% for both years; P=.0585), while the proportion that were rTSA surpassed aTSA in 2014, increasing from 33% to 46% (P<.0001). Use of rTSA topped use of aTSA by 2013 for Medicare patients. The proportion that were HA procedures declined from 23% to 11% (P<.0001). The use of rTSA for fracture increased from 26% to 58% (P<.0001) of all arthroplasties for this indication, while the use of HA for fracture decreased from 69% to 40% (P<.0001). Orthopedists performed rTSA more often than aTSA for Medicare patients by 2013 and the general population by 2014. The use of rTSA for fracture has grown significantly, with rTSA being performed more frequently than HA for this indication. [Orthopedics. 2018; 41(3):e416-e423.].
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http://dx.doi.org/10.3928/01477447-20180409-05DOI Listing
May 2018

Survey of shoulder arthroplasty surgeons' methods for infection avoidance of .

J Orthop 2018 Mar 2;15(1):177-180. Epub 2018 Feb 2.

Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, United States.

Introduction: infection after shoulder arthroplasty remains a source of morbidity. Determining practices amongst shoulder surgeons is the first step in developing infection-prevention best-practices.

Methods: A survey was sent to a shoulder fellowship alumni group to determine their arthroplasty infection prevention methods.

Results: 74% completed the survey. Cefazolin (90%), vancomycin (50%) and clindamycin (18%) were the most commonly used antibiotics, 61% utilized more than one antibiotic. Most (76%) reported using an experience-based protocol learned during residency/fellowship.

Discussion And Conclusion: There are no clear standards for prevention of infections in shoulder arthroplasty. There is a general non-scientific approach to the prevention of shoulder arthroplasty infection.
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http://dx.doi.org/10.1016/j.jor.2018.01.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895935PMC
March 2018
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