Publications by authors named "Joseph A Abboud"

169 Publications

Orthopedic Specialty Hospitals Are Associated With Lower Rates of Deep Surgical Site Infection Compared With Tertiary Medical Centers.

Orthopedics 2021 Jul-Aug;44(4):e521-e526. Epub 2021 Jul 1.

Orthopedic specialty hospitals may allow for more streamlined and efficient care, resulting in shorter lengths of stay, lower costs, and fewer complications. Surgical site infection can be a devastating complication of orthopedic procedures and is difficult to treat successfully, requiring substantial cost and resources. The goal of this study was to determine whether specialty hospitals had lower rates of infection than tertiary care institutions. Records were reviewed for patients undergoing primary total hip, knee, or shoulder arthroplasty and single-level lumbar fusion from 2010 to 2017 at 2 academic tertiary hospitals and 2 specialty hospitals. Patient demographic information, comorbidities, and the development of deep surgical site infection within 1 year of the index procedure were recorded and compared between the groups. Multivariate analysis identified variables that significantly correlated with infection rates. A total of 20,264 patients (73.9%) underwent surgery at a tertiary hospital, and 7169 (26.1%) underwent a procedure at a specialty hospital. Patients treated at orthopedic specialty hospitals had lower rates of infection at 1 year (0.6% vs 0.2%, <.0001). Of the infections, 42 (32.3%) occurred in the knee, 50 (38.5%) in the hip, 24 (18.5%) in the spine, and 12 (10.8%) in the shoulder. When controlling for a healthier patient population, procedures performed at specialty hospitals were an independent predictor of infection within 1 year (odds ratio, 0.3693; =.0012). Although tertiary hospitals care for older patients with more medical comorbidities, patients undergoing orthopedic procedures at a specialty hospital may be at lower risk for infection. Further study is needed to identify the processes associated with reduced infection rates and to determine whether they can be adopted at tertiary centers. [. 2021;44(4):e521-e526.].
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http://dx.doi.org/10.3928/01477447-20210618-11DOI Listing
July 2021

Distinct Gene Expression Profile in Patients With Poor Postoperative Outcomes After Rotator Cuff Repair: A Case-Control Study.

Am J Sports Med 2021 Jul 20:3635465211023212. Epub 2021 Jul 20.

Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA.

Background: Impaired healing after rotator cuff repair is a major concern, with retear rates as high as 94%. A method to predict whether patients are likely to experience poor surgical outcomes would change clinical practice. While various patient factors, such as age and tear size, have been linked to poor functional outcomes, it is currently very challenging to predict outcomes before surgery.

Purpose: To evaluate gene expression differences in tissue collected during surgery between patients who ultimately went on to have good outcomes and those who experienced a retear, in an effort to determine if surgical outcomes can be predicted.

Study Design: Case-control study; Level of evidence, 3.

Methods: Rotator cuff tissue was collected at the time of surgery from 140 patients. Patients were tracked for a minimum of 6 months to identify those with good or poor outcomes, using clinical functional scores and follow-up magnetic resonance imaging to confirm failure to heal or retear. Gene expression differences between 8 patients with poor outcomes and 28 patients with good outcomes were assessed using a multiplex gene expression analysis via NanoString and a custom-curated panel of 145 genes related to various stages of rotator cuff healing.

Results: Although significant differences in the expression of individual genes were not observed, gene set enrichment analysis highlighted major differences in gene sets. Patients who had poor healing outcomes showed greater expression of gene sets related to extracellular matrix production ( < .0001) and cellular biosynthetic pathways ( < .001), while patients who had good healing outcomes showed greater expression of genes associated with the proinflammatory (M1) macrophage phenotype ( < .05).

Conclusion: These results suggest that a more proinflammatory, fibrotic environment before repair may play a role in poor healing outcome. With validation in a larger cohort, these results may ultimately lead to diagnostic methods to preoperatively predict those at risk for poor surgical outcomes.
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http://dx.doi.org/10.1177/03635465211023212DOI Listing
July 2021

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

Consensus Statement on the Treatment of Massive Irreparable Rotator Cuff Tears - A Delphi Approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

J Shoulder Elbow Surg 2021 Jun 8. Epub 2021 Jun 8.

Department of Orthopedic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.

Background: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial due to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons (ASES) to determine areas of consensus regarding treatment options for a variety of MIRCTs.

Methods: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including: arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfers. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the six included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either: Preferred treatment, Acceptable treatment, Not acceptable/contraindicated, or Unsure/no opinion. Patient scenarios were declared to achieve consensus for the Preferred and Not acceptable/contraindicated categories where at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the Acceptable treatment category, defined by an Acceptable or Preferred treatment response.

Results: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an Acceptable treatment with RSA selected for eighteen scenarios and arthroscopic débridement and/or partial repair selected for two scenarios. RSA was selected as the singular Preferred treatment option in eight scenarios. Not acceptable/contraindicated treatment options reached consensus in eight scenarios, of which, four related to SCR, three to RSA, and one to partial repair with graft augmentation.

Conclusion: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

Level Of Evidence: Survey Study; Experts.
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http://dx.doi.org/10.1016/j.jse.2021.05.012DOI Listing
June 2021

Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs.

Am J Sports Med 2021 Jul 20;49(8):2042-2047. Epub 2021 May 20.

Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.

Background: Primary rotator cuff repairs in complex cases (older patient age, larger tear sizes, chronic tears) and revision repairs are at high risk for failure of healing.

Purpose: To examine clinical outcomes and healing rates in complex and revision rotator cuff repairs with dermal allograft augmentation.

Study Design: Case series; Level of evidence, 4.

Methods: A retrospective study was made of cases performed by 3 fellowship-trained surgeons via a uniform technique involving rotator cuff repairs with allograft augmentation. In all cases, a 1.5-mm, human, decellularized dermal graft was tied on top of the tendon at the medial row and compressed to the rotator cuff footprint using a double-row technique. Postoperative magnetic resonance imaging (MRI) was performed at a minimum of 6 months and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and 12-Item Short Form Health Survey scores were collected at a minimum of 2 years postoperatively.

Results: A total of 35 patients (23 revision repairs, 12 primary complex repairs) were included. The mean patient age was 57.9 years (range, 41.0-70.5 years). All shoulders had 2-tendon tears (supraspinatus and infraspinatus), and 8 included the upper 50% of the subscapularis. At a minimum of 2 years after surgery (mean, 3.2 years), mean ASES and SANE scores improved from 42.4 and 35.3 to 77.6 and 73.5, respectively ( < .001). In the 23 patients (66%) with postoperative MRI evaluation, 11 (48%) had images showing the tendons were retorn. ASES (89.7 vs 66.4; = .04) and SANE (84.1 vs 50.5; = .02) scores were higher in healed patients than those with retears. The retear group had a higher degree of preoperative fatty atrophy of the infraspinatus ( = .024).

Conclusion: Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. Approximately half of patients experienced a failure of healing, which was associated with poorer functional results.
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http://dx.doi.org/10.1177/03635465211015194DOI Listing
July 2021

Outcomes of rotator cuff repair with concurrent microfracture of focal glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2021 Jul 21;30(7S):S66-S70. Epub 2021 Apr 21.

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

Background: The benefit of rotator cuff repair (RCR) in patients with concurrent osteoarthritic changes remains unclear. RCR has the theoretical potential to increase the compressive force across the glenohumeral joint, further exacerbating osteoarthritis pain. The purpose of this study is to investigate pain relief and patient-reported outcomes of patients undergoing simultaneous RCR and microfracture of focal glenohumeral osteoarthritis.

Methods: Thirty-four patients undergoing simultaneous RCR and microfracture were retrospectively reviewed at a minimum 1-year follow-up. Patient demographics, preoperative range of motion, functional outcomes (visual analog scale [VAS], Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Simple Shoulder Test [SST]), and operative metrics were recorded. The patients were then contacted to obtain postoperative functional outcome scores (VAS, SANE, ASES, and SST).

Results: Twenty-seven patients (11 male/16 female [79%]) were evaluated at a mean follow-up of 25.8 months (range, 12-46). The average age at surgery was 64.9 years (range, 56-78). Chronic tears were more common than acute tears (57.7% vs. 42.3%). The majority of patients had a full rotator cuff tear (89%) involving a mean 1.7 ± 0.8 tendons (range, 1-3). Eighty-eight percent of the humeral lesions were Outerbridge 4 compared with 84% on the glenoid. The mean estimated involvement between the 2 groups with 38.4% ± 18.4% of the humeral head involved and 34.6% ± 18.4% of the glenoid involved. PRO scores improved postoperatively with a reduction in mean VAS (6.6-2.0, P < .01), SANE (33.8-79.8, P < .01), ASES (38.0-80.9, P < .01), and SST (3.07-9.70, P < .01) scores. Cumulatively, only 52% (14/27) of the patients improved, however, by the MCID for all collected PROs.

Conclusions: Our results demonstrate modest improvements in postoperative pain and functional scores at a minimum of 1-year follow-up in a cohort of patients who have undergone RCR and glenohumeral microfracture. In cases of small focal lesions of full-thickness cartilage loss, RCR with microfracture is a reasonable treatment option; however, patients should be counseled on expectations accordingly.
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http://dx.doi.org/10.1016/j.jse.2021.04.008DOI Listing
July 2021

Needle-Based Arthroscopic Transosseous Rotator Cuff Repair: A Short-Term Outcomes Analysis.

Cureus 2021 Feb 27;13(2):e13595. Epub 2021 Feb 27.

Shoulder and Elbow Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, USA.

Introduction Given the limitations of anchor-based rotator cuff repair, surgeons have considered and investigated the use of an arthroscopic transosseous repair technique using only sutures to repair tendon tissue. Returning full circle to the gold standard of transosseous repair, but with the modern adaptation of arthroscopy, advocates of arthroscopic transosseous rotator cuff repair believe that many of the risks associated with suture anchors can be avoided. The purpose of this study was to examine the capabilities of a novel needle-based arthroscopic transosseous tunneling device (OmniCuff™ arthroscopic transosseous device, MinInvasive Ltd., Magal, Israel) and evaluate the short-term clinical outcomes and patient satisfaction of patients treated with this technique. Materials and methods This study was a prospective, single-arm, multi-center study performed on patients from January 2014 to March 2015. During the study period, thirty-two patients underwent arthroscopic transosseous rotator cuff repair using the OmniCuff™ arthroscopic transosseous device. Results The average age of patients was 58.2 years (range, 44 to 80 years). The sizes of the tears were as follows: seven small, 18 medium, four large, and three massive. The average number of tunnels used per repair was 1.9 with the following breakdown: six one-tunnel repairs, 22 two-tunnel repairs, and four three-tunnel repairs. The mean American Shoulder and Elbow Surgeon (ASES) score improved from 45.1 to 87.7, the mean Simple Shoulder Test (SST) score improved from 42.6 to 92. Overall patient satisfaction was high with an average Likert scale of 4.6. Conclusion Our study demonstrated significantly improved outcomes for patients undergoing arthroscopic transosseous rotator cuff repair using the needle based Omnicuff device. Patients were overall very satisfied with the outcome of their surgery and their ASES and SST scores demonstrated this appropriately.
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http://dx.doi.org/10.7759/cureus.13595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007122PMC
February 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

Outcomes of chronic distal biceps reconstruction with tendon grafting: a matched comparison with primary repair.

JSES Int 2021 Mar 19;5(2):302-306. Epub 2020 Dec 19.

The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, PA, USA.

Background: The purpose of this analysis was to analyze outcomes of distal biceps reconstruction with soft tissue allograft in the setting of chronic, irreparable distal biceps ruptures. The outcomes of these cases were then compared with a matched cohort of distal biceps ruptures that were able to be repaired primarily.

Methods: Retrospective review of an institutional elbow surgery database was conducted. All cases of distal biceps repairs were identified by Common Procedural Terminology, ICD-9, and ICD-10 codes from January 2009 to March 2018. A direct review of operative reports was then conducted to identify which cases required allograft reconstruction. After identification of this population, a 2:1 manually matched cohort of patients who underwent primary repair was generated using age, gender, body mass index, and age-adjusted Charlson Comorbidity Index. Finally, the allograft reconstruction and matched primary repair cohorts were compared for reoperation, range of motion, and patient-reported outcomes scores.

Results: There were 46 male patients who underwent distal biceps reconstruction with allograft (14 Achilles tendon, 32 semitendinosus) and they were matched to 92 male patients that underwent primary distal biceps repair. Mean patient age (46.9 ± 10.3 vs. 47.0 ± 9.8 years,  = .95), BMI (31.3 ± 5.3 vs. 31.3 ± 4.8 kg/m,  = .60), and Charlson Comorbidity Index (1.2 ± 1.1 vs. 1.3 ± 0.9,  = .64) were similar between allograft reconstruction and primary repair groups. Disability of the Arm, Shoulder and Hand score (7.4 ± 18.0 vs. 1.6 ± 4.1,  = .23), Mayo Elbow Performance Score (92.1 ± 19.7 vs. 97.3 ± 6.4,  = .36), and Oxford Elbow Score (43.4 ± 11.0 vs. 46.8 ± 3.2,  = .25) were not significantly different between groups at mean 5.1 years (range, 1.5-10.9 years) after surgery. There were 1 of 42 (2.2%) allograft patients who require revision compared with 3 of 92 (3.3%,  = .719) in the primary repair group. In addition, one primary repair required reoperation for scar tissue excision and lateral antebrachial cutaneous neurolysis. Final range of motion data (twelve-week follow-up) for the allograft reconstruction group was similar to primary repair group in flexion (136.1° ± 5.3° vs. 135.9° ± 2.7°,  = .81), extension (0.8° ± 2.9° vs. 0.4° ± 1.7°,  = .53), pronation (78.0° ± 9.0° vs. 76.4° ± 15.4°,  = .50), supination (77.4° ± 10.7° vs. 77.5° ± 11.9°,  = .96).

Conclusion: Patients who underwent distal biceps reconstruction with a graft had similar failure rates, reoperation rates, final range of motion, and patient-reported outcomes scores as those treated without a graft. Patients can be consulted that direct repair in the acute setting is preferred; however, even in the setting of a distal biceps reconstruction with graft augmentation, they can expect low complications and good functional results.
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http://dx.doi.org/10.1016/j.jseint.2020.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910717PMC
March 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

Concomitant rotator cuff repair and instability surgery provide good patient-reported functional outcomes in patients aged 40 years or older with shoulder dislocation.

JSES Int 2020 Dec 17;4(4):792-796. Epub 2020 Sep 17.

Rothman Orthopaedic Institute, Philadelphia, PA, USA.

Background: Recurrent anterior shoulder dislocation in patients aged ≥ 40 years is not as rare as once thought. The mechanism of instability in this patient population is different-more likely to be attributed to rotator cuff pathology-compared with that in younger individuals. With an increasingly aging active population, surgical management has a rising role in preventing morbidity associated with recurrent instability. Our purpose was to evaluate outcomes of anterior shoulder instability repair (ie, Bankart or bony Bankart repair) with and without rotator cuff repair (RCR) in patients aged ≥ 40 years.

Methods: We conducted a retrospective chart review of all patients aged ≥ 40 years who underwent surgical repair for anterior shoulder instability from 2008-2016. Patients were categorized into 4 cohorts: Bankart repair only, bony Bankart repair only, Bankart repair with concomitant RCR, and bony Bankart repair with concomitant RCR. Demographic and history-of-instability data were collected. Clinical and functional outcomes assessed included the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons score, Penn Shoulder Score, visual analog scale score for pain, Western Ontario Shoulder Instability Index score, and patient satisfaction score.

Results: A total of 146 patients were included in this study, with 103 patients (71%) having ≥2-year outcome scores. Outcome scores were not significantly different among groups. For patients who underwent Bankart repair only, bony Bankart repair only, Bankart repair with RCR, and bony Bankart repair with RCR, the Single Assessment Numeric Evaluation scores were 80.8 ± 19.7, 90.0 ± 10.7, 79.3 ± 29.4, and 87.2 ± 10.6, respectively ( = .284); American Shoulder and Elbow Surgeons scores, 83.8 ± 19.7, 92.4 ± 17.4, 82.5 ± 25.6, and 85.6 ± 12.7, respectively ( = .114); Penn Shoulder Scores for function, 84.5 ± 17.9, 90.9 ± 15.3, 83.6 ± 25.1, and 95.7 ± 13.0, respectively ( = .286); and Western Ontario Shoulder Instability Index scores, 481.0 ± 519.5, 292.1 ± 414.3, 548.9 ± 690.5, and 320.6 ± 258.7, respectively ( = .713). Age at the time of surgery significantly differed between cohorts ( < .001). No patients had recurrence of instability during the study period.

Conclusion: Similar functional outcomes can be achieved in the surgical management of anterior instability in patients aged ≥ 40 years. Rotator cuff tears should be suspected and repaired in patients with anterior instability, especially those aged ≥ 50 years.
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http://dx.doi.org/10.1016/j.jseint.2020.08.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738596PMC
December 2020

Improving Efficiency of Patient-Reported Outcome Collection: Application of Computerized Adaptive Testing to DASH and QuickDASH Outcome Scores.

J Hand Surg Am 2021 Apr 17;46(4):278-286. Epub 2020 Dec 17.

Rothman Orthopaedic Institute, Philadelphia, PA. Electronic address:

Purpose: Patient-reported outcome measures assess health status and treatment outcomes in orthopedic care, but they may burden patients with lengthy questionnaires. Predictive models using machine learning, known as computerized adaptive testing (CAT), offer a potential solution. This study evaluates the ability of CAT to improve efficiency of the 30-item Disabilities of the Arm, Shoulder, and Hand (DASH) and 11-item QuickDASH questionnaires.

Methods: A total of 2,860 DASH and 27,355 QuickDASH respondents were included in the analysis. The CAT system was retrospectively applied to each set of patient responses stored on the instrument to calculate a CAT-specific score for all DASH and QuickDASH entries. The accuracy of the CAT scores, viewed in the context of the minimal clinically important difference for both patient-reported outcome measures (DASH, 12; QuickDASH, 9), was determined through descriptive statistics, Pearson correlation coefficient, intraclass correlation coefficient, and distribution of scores and score differences.

Results: The CAT model required an average of 15.3 questions to be answered for the DASH and 5.8 questions for the QuickDASH, representing a 49% and 47% decrease in question burden, respectively. Mean CAT score was the same for DASH and 0.1 points lower for QuickDASH with similar SDs (DASH, 12.9 ± 19.8 vs 12.9 ± 19.9; QuickDASH, 32.7 ± 24.7 vs 32.6 ± 24.6). Pearson coefficients (DASH, 0.99; QuickDASH, 0.98) and intraclass correlation coefficients (DASH, 1.0; QuickDASH, 0.98) indicated strong agreement between scores. The difference between the CAT and full score was less than the minimal clinically important difference in 99% of cases for DASH and approximately 95% of cases for QuickDASH.

Conclusions: The application of CAT to DASH and QuickDASH surveys demonstrated an ability to lessen the response burden with negligible effect on score integrity.

Clinical Relevance: In the case of DASH and QuickDASH, CAT is an appropriate alternative to full questionnaire implementation for patient outcome score collection.
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http://dx.doi.org/10.1016/j.jhsa.2020.10.021DOI Listing
April 2021

Humeral Shaft Fractures: Surgical versus Nonsurgical Management in Workers' Compensation.

Arch Bone Jt Surg 2020 Nov;8(6):668-674

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

Background: The optimal surgical indications for humeral shaft fractures in the working population remain uncertain. This study investigates the impact of surgical fixation on return to duty, union, and complications in workers' compensation patients with humeral shaft fractures.

Methods: All workers' compensation patients with humeral shaft fractures managed at a single institution between 2007 and 2017 were identified. Manual chart and radiographic review was performed to identify etiology of injury, type of work, time until return to duty, length of physical therapy, complications, and time to fracture union.

Results: There were 39 humeral shaft fractures in workers' compensation patients managed at our institution (25 surgical; 64.1%). There was no difference in the return to light (106.1 versus 60.4 days; ) or full (140.1 vs. 139.9 days; ) duty for surgical versus nonsurgical treatment, respectively. There was no difference in the length of physical therapy (132.6 versus 106.3 days; ) or time to maximum medical improvement (174.3 vs. 198.8 days; ) for surgical versus nonsurgical treatment, respectively. Three patients returned to the operating room in the surgical group. Nonunion was observed in two surgical cases (8.0%) and one case (7.1%) of nonsurgical management.

Conclusion: This study did not identify an advantage for faster return to work after surgical management of humeral shaft fractures in workers' compensation patients. Though one of the perceived advantages of surgical fixation is a quicker return to physical activity, there may be other variables in this patient population that influence the timing of return to work.
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http://dx.doi.org/10.22038/abjs.2020.44301.2211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7718578PMC
November 2020

Doping in the Ultimate Fighting Championship (UFC): A 4-year epidemiological analysis.

Drug Test Anal 2021 Apr 22;13(4):785-793. Epub 2020 Dec 22.

The Rothman Institute, Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background: Doping is a practice that is present in many sports and organizations, including mixed martial arts and the Ultimate Fighting Championship (UFC). The aim of this study is to explore the epidemiological patterns of doping among UFC athletes.

Methods: We screened the official United-States-Anti-Doping-Agency® (USADA) website, the annual USADA reports and the official UFC website for information on fighters and anti-doping rule violations (ADRVs). Our dataset included gender, age, weight class, testing numbers, date of ADRV, type of ADRV, and duration of suspension. Appropriate statistical tests were conducted to assess for statistical significance.

Results: USADA tested 1070 UFC athletes 2624 times as of late 2015 up till the end of 2019 (N = 1070). A total of 209 adverse findings were recorded; out of which, 102 ADRVs were committed by 93 athletes (8.7%) from all weight divisions. This constituted an adverse finding rate of 16.55 per 1000 test and an ADRV rate of 8.08 per1000 test. Mean age of sanctioned athletes was 32 years. Use of anabolic steroids was significantly the most common ADRV recorded (p = 0.018). The men's heavyweight division had an ADRV rate of 19.3 per 1000 tests, significantly higher than that of women's bantamweight division at 2 per 1000 tests (p = 0.03), women's featherweight division at 0 per 1000 tests (p = 0.009), and men's flyweight division at 3 per 1000 tests (p = 0.035). ADRV rate showed a significantly increasing trend among men's weight divisions (p < 0.001).

Conclusion: Doping is present in mixed martial arts. Increasing testing numbers, raising awareness and education on the risks of doping, and conducting further research on the issue is key to help resolve this problem.
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http://dx.doi.org/10.1002/dta.2987DOI Listing
April 2021

Craniofacial and traumatic brain injuries in mixed martial arts.

Phys Sportsmed 2020 Dec 3:1-9. Epub 2020 Dec 3.

Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon.

: Mixed-Martial-Arts (MMA) has witnessed a rapid growth over the recent years. This study aims to explore the patterns and trends of head injuries in MMA.: Descriptive epidemiological study.: Ringside physician reports of the Ultimate Fighting Championship (UFC) fights between 2016 and 2019 (inclusive) were screened. Data were extracted from the Nevada State Athletic Commission (NSAC) database. Play-by-play video analysis was also conducted.: UFC fighters involved in fights sanctioned by the NSAC, between 2016 and the end of 2019 (N = 816).: Sex, location of head injury, type of head injury, injury mechanism, number of significant head strikes, type of finish, and weight division.: Head injury rates were calculated. A one-way analysis of variance (ANOVA) was used to explore any statistically significant differences between injury rates of different locations, types, and types of finishes. An independent t-test was used to determine whether any significant differences existed between the two sexes, and a Joinpoint regression analysis was used to determine the statistical significance of the trends of head injury rates across different weight divisions. P-values <0.05 were considered significant (95% CI).: A total of 288 head injuries in 408 fights were recorded during our study period. Head injury rate constituted 35 injuries per 100 athletic-exposures (AE) in sanctioned fights. Traumatic brain injuries (TBI) were the most common type of injury, with a rate of 16 per 100AE, significantly greater than that of fractures (p = 0.003). Males had a head injury rate of 37 per 100AE, higher than that of females which was 23 per 100AE. Technical Knockout (TKO)/ Knockout(KO) was the type of finish with the highest rate of head injuries, significantly greater than that of decision or submission (p < 0.001). In general, head injury rates were higher as weight divisions increased.: Head injuries are prevalent in MMA. Preventive measures need to be implemented to ensure fighter safety and limit injury risk.
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http://dx.doi.org/10.1080/00913847.2020.1847623DOI Listing
December 2020

Incidence of peripheral nerve injury in revision total shoulder arthroplasty: an intraoperative nerve monitoring study.

J Shoulder Elbow Surg 2021 Jul 20;30(7):1603-1612. Epub 2020 Oct 20.

Department of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA.

Background: The incidence of nerve injuries in revision total shoulder arthroplasty (TSA) is not well defined in the literature and may be higher than that in primary procedures, with 1 study reporting a complication rate of 50% for shoulder revisions. Given that continuous intraoperative nerve monitoring (IONM) can be an effective tool in diagnosing evolving neurologic dysfunction and preventing postoperative injuries, the purpose of this study was to report on IONM data and nerve injury rates in a series of revision TSAs.

Methods: A retrospective cohort review of consecutive patients who underwent revision TSA was performed from January 2016 to March 2020. Indications for revision included infection (n = 7); failed total arthroplasty and hemiarthroplasty secondary to pain, dysfunction, and/or loose components (n = 36); and periprosthetic fracture (n = 1). Of the shoulders, 32 underwent revision to a reverse TSA, 6 underwent revision to an anatomic TSA, and 6 underwent spacer placement. IONM data included transcranial electrical motor evoked potentials (MEPs), somatosensory evoked potentials, and free-run electromyography. The motor alert threshold was set at ≥80% signal attenuation in any peripheral nerve. Patients were screened for neurologic deficits immediately following surgery, prior to administration of an interscalene nerve block, and during the first 2 postoperative visits. Additional data collection included surgical indication, sex, laterality, age at surgery, procedure performed, body mass index, history of tobacco use, Charlson Comorbidity Index, medical history, and preoperative range of motion.

Results: A total of 44 shoulders in 38 patients were included, with a mean age of 63.2 years (standard deviation, 13.0 years). Of the procedures, 22.4% (n = 10) had an MEP alert, with 8 isolated to a single nerve (7 axillary and 1 radial) and 1 isolated to the axillary and musculocutaneous nerves. Only 1 patient experienced a major brachial plexus alert involving axillary, musculocutaneous, radial, ulnar, and median nerve MEP alerts, as well as ulnar and median nerve somatosensory evoked potential alerts. Age, sex, body mass index, Charlson Comorbidity Index, and preoperative range of motion were not found to be significantly different between cases in which an MEP alert occurred and cases with no MEP alerts. In the postoperative period, no minor or major nerve injuries were found whereas distal peripheral neuropathy developed in 4 patients (9.1%).

Conclusion: Among 44 surgical procedures, no patients (0%) had a major or minor nerve injury postoperatively and 4 patients (9.1%) complained of distal peripheral neuropathy postoperatively. In this study, we have shown that through the use of IONM, the rate of minor and major nerve injuries can be minimized in revision shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jse.2020.09.024DOI Listing
July 2021

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years.

J Shoulder Elbow Surg 2021 Jun 30;30(6):e300-e308. Epub 2020 Sep 30.

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

Background: The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications.

Methods: This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence.

Results: During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1 brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases.

Conclusion: The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.
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http://dx.doi.org/10.1016/j.jse.2020.09.002DOI Listing
June 2021

Outcome measures reported for the management of proximal humeral fractures: a systematic review.

J Shoulder Elbow Surg 2020 Oct 9;29(10):2175-2184. Epub 2020 Jun 9.

Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA. Electronic address:

Background: The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

Methods: A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

Results: Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

Conclusion: Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.
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http://dx.doi.org/10.1016/j.jse.2020.04.006DOI Listing
October 2020

The effect of critical shoulder angle on functional compensation in the setting of cuff tear arthropathy.

JSES Int 2020 Sep 19;4(3):601-605. Epub 2020 Jun 19.

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

Introduction: Critical shoulder angle (CSA) has been shown to influence rates of rotator cuff tears and glenohumeral arthritis with a larger CSA associated with rotator cuff tears and a smaller CSA associated with glenohumeral arthritis. There has been no study to determine whether such radiographic measurement influences the function of patients with demonstrated cuff tear arthropathy (CTA). The purpose of this study was to examine whether smaller CSAs were associated with greater range of motion (ROM) in patients diagnosed with CTA.

Materials And Methods: Ninety-three patients with a diagnosis of CTA with adequate anteroposterior shoulder radiographs were included in the study. Patient demographics were recorded. The presence of a rotator cuff tear was confirmed via advanced imaging or when applicable via the operative report. Patients' ROM was evaluated through the physician's office note. Shoulder radiographs were used to measure CSA, glenoid inclination, acromial index (AI), and acromiohumeral interval. Patient ROM was measured and grouped into 2 different tiered cohorts: cohort 1 had 4 subgroups of forward elevation (FE) (ie, ≤45°, 45°-90°, 91°-135°, and 136°-180°) and cohort 2 had 2 subgroups of FE (ie, ≤90° and >90°). We then analyzed FE between these groups in the context of their radiographic measurements.

Results: The average patient age was 73.8 ± 8.0 years. There was no significant difference in acromiohumeral interval. AI was found to be significantly different between patients presenting with ≤90° in FE compared with those >90° ( = .02). Average CSA was significantly lower in patients with FE greater than 90° at 33.7° ± 3.9° compared with patients with FE less than 90° at 37.1° ± 6.3° ( = .002). There was also a significant difference with regard to CSAs, with those patients with FE ≤ 45° having a mean CSA of 38.2° ± 8.3° compared with those patients with FE ≥ 135° having a mean CSA of 33.3° ± 4.3° ( = .02).

Conclusion: Patients diagnosed with CTA can significantly vary in their shoulder function and ability to forward elevate. Lower CSA was found to be associated with higher FE in patients with CTA preoperatively. In addition, patients with a smaller AI were also found to have better overhead function. Analyzing CSA on plain radiographs may help manage functional expectations in patients with CTA.
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http://dx.doi.org/10.1016/j.jseint.2020.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479159PMC
September 2020

What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty?

J Shoulder Elbow Surg 2021 Jun 10;30(6):1324-1328. Epub 2020 Sep 10.

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

Background: Cultures taken at the time of primary shoulder arthroplasty are commonly positive for Cutibacterium acnes. Despite our limited understanding of the clinical implication of deep tissue inoculation from dermal colonization, significant efforts have been made to decolonize the shoulder prior to surgery. The purpose of this study is to determine differences in clinical outcomes based on culture positivity at the time of primary shoulder arthroplasty.

Methods: A series of 134 patients who underwent primary anatomic or reverse total shoulder arthroplasty and had intraoperative cultures obtained via a standard protocol were included. In each case, 5 tissue samples were collected and processed in a single laboratory for culture on aerobic and anaerobic media for 13 days. Minimum 2-year functional outcomes scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Single Assessment Numeric Evaluation [SANE]) and reoperation data were analyzed.

Results: Forty-two (31.3%) patients had positive cultures (30 C acnes and 21 with at least 2 positive cultures) at the time of surgery. There was no statistically significant difference in postoperative functional outcome scores (ASES: 82.5 vs. 81.9; P = .89, SANE: 79.5 vs. 82.1; P = .54) between culture-positive and culture-negative cohorts. There were no cases of infection. Two patients (4.8%; 2/42) with positive cultures required reoperation compared with 4 patients (5.6%; 4/71) without positive cultures.

Conclusion: The apparent colonization by nonvirulent organisms in patients undergoing primary shoulder arthroplasty does not appear to have a clinically significant effect on functional outcomes or need for repeat surgery in the short term.
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http://dx.doi.org/10.1016/j.jse.2020.08.032DOI Listing
June 2021

Perioperative pain management for shoulder surgery: evolving techniques.

J Shoulder Elbow Surg 2020 Nov 9;29(11):e416-e433. Epub 2020 Jun 9.

Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA.

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.
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http://dx.doi.org/10.1016/j.jse.2020.04.049DOI Listing
November 2020

Synovial Fluid Volume at the Time of Arthroscopic Rotator Cuff Repair Correlates With Tear Size.

Cureus 2020 Jul 16;12(7):e9224. Epub 2020 Jul 16.

Shoulder and Elbow Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, USA.

Background Inflammatory biomarkers are increased in the synovium and tendon of rotator cuff tears. Several studies demonstrate an associated increase in these markers and size of the tear, with implications of chondral destruction leading to rotator cuff tear arthropathy and glenohumeral arthritis. Methods This is a prospective study of 105 patients undergoing arthroscopic rotator cuff repair in which intra-articular synovial fluid was aspirated just prior to arthroscopy. Adult patients with a partial or full-thickness rotator cuff tear undergoing arthroscopic repair were included, and those with inflammatory arthritis, active infection, open cuff repair, intraoperative findings of osteoarthritis, or those undergoing revision cuff repair were excluded. Results The average patient age was 58 years (range 33-74 years), with 59 (56.2%) males. The mean aspirate volume of partial tears was 0.76 ± 0.43 mL, small tears 1.46 ± 1.88 mL, medium tears 3.04 ± 2.21 mL, and large tears 6.60 ± 3.23 mL. Full-thickness versus partial tears had significantly more synovial fluid (3.64 vs. 0.76 mL, respectively, p < 0.0001). An aspiration volume of 1.5 mL or greater resulted in 91.3% specificity and 96.8% positive predictive value for a full-thickness tear. Smoking (p = 0.017), tear size (p < 0.0001), and tears of the infraspinatus (p = 0.048) were significantly correlated with synovial fluid volume. Age, body mass index, chronicity of tear, sex, subscapularis involvement, supraspinatus involvement, and teres minor involvement had no association to synovial fluid volume. Conclusion Preoperative aspiration of the glenohumeral joint to identify the volume of synovial fluid can aid to identify full-thickness rotator cuff tears, and increased fluid volume should alert the clinician of a large tear.
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http://dx.doi.org/10.7759/cureus.9224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430535PMC
July 2020

Surgical Treatment of Adhesive Capsulitis: A Retrospective Comparative Study of Manipulation Under Anesthesia and/or Capsular Release.

Cureus 2020 Jul 6;12(7):e9032. Epub 2020 Jul 6.

Shoulder and Elbow Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, USA.

Background No consensus exists among orthopedic surgeons regarding the optimal intervention for adhesive capsulitis. The purpose of this study was to determine which treatment provides the best objective outcome following manipulation under anesthesia (MUA), MUA + arthroscopic capsular release (CR), or CR alone. Methods Between 2011 and 2015, 97 shoulders were treated for adhesive capsulitis (MUA, MUA+CR, CR) and followed for three months or until achieving full range of motion (ROM). Patients' charts were reviewed for demographic information, diabetes, pre/post-operative ROM, and complications. Results The average age at surgery was 57 years (range: 31-80 years) with a mean follow-up of 6.2 months (range: 2-43 months). ROM improved significantly regardless of treatment modality (p < 0.001). MUA had significantly more external rotation at follow-up than MUA+CR and CR alone (62 vs 49 vs 48, p = 0.02). Groups were similar in regards to post-operative elevation and internal rotation. Loss of external rotation following surgery was significantly more common in the MUA+CR group (p = 0.03). In diabetics, no treatment option was superior to another in regards to final ROM. Conclusion Operative treatment of idiopathic adhesive capsulitis is efficacious and safe for improving shoulder ROM across treatment modalities. Surgeon preference may effectively guide treatment independent of diabetic status.
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http://dx.doi.org/10.7759/cureus.9032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406188PMC
July 2020

Orthopaedic Considerations Following COVID-19: Lessons from the 2003 SARS Outbreak.

JBJS Rev 2020 07;8(7):e2000052

1Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.2106/JBJS.RVW.20.00052DOI Listing
July 2020

Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference?

J Shoulder Elbow Surg 2021 Jan 9;30(1):51-56. Epub 2020 Jun 9.

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

Background: Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend toward shorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy.

Methods: We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem design were collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft angle were performed. Restoration of the native humeral anatomy was deemed "acceptable" based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed.

Results: In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptable HH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P < .001).

Conclusion: Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.
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http://dx.doi.org/10.1016/j.jse.2020.04.014DOI Listing
January 2021

Quantitative ultrahigh-molecular-weight polyethylene wear in total elbow retrievals.

J Shoulder Elbow Surg 2020 Nov 9;29(11):2364-2374. Epub 2020 Jun 9.

Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, USA; Exponent, Inc., Philadelphia, PA, USA.

Background: The purpose of this study was to evaluate ultrahigh-molecular-weight polyethylene (UHMWPE) wear and damage from retrieved total elbow arthroplasty components and compare in vivo wear with wear produced in vitro.

Methods: Explanted total elbow components were collected at revision surgery. UHMWPE damage was characterized visually, whereas penetration and wear were quantified using micro-computed tomography and gas pycnometry. Volumetric wear rates were compared with historical hip data, and wear data were compared with reported in vitro wear test data.

Results: Humeral bushing damage primarily occurred in the form of burnishing, scratching, and pitting at the articular face in the region of contact with the ulnar component. Wear of the ulnar bushings was concentrated on the edge of the component at the point of contact with the axis pin. Pitting and embedded debris were dominant damage modes, in addition to burnishing and delamination. Backside wear was negligible. The median linear penetration rates of the lateral, medial, and ulnar bushings were 0.14 mm/yr (range, 0.01-0.78 mm/yr), 0.12 mm/yr (range, 0.03-0.55 mm/yr), and 0.11 mm/yr (range, 0.01-0.69 mm/yr), respectively. The volumetric wear rates of the lateral, medial, and ulnar bushings were 5.5 mm/yr (range, 0.7-37.2 mm/yr), 5.9 mm/yr (range, 0.6-25.5 mm/yr), and 5.5 mm/yr (range, 1.2-51.2 mm/yr), respectively.

Conclusions: The observed wear rates were similar to those reported in well-functioning total hip replacement patients with conventional UHMWPE bearings. We found limitations in reported in vitro testing resulting in wear that was not consistent with our retrieval data. We recommend further investigation to clinically validate in vitro simulation to provide appropriate loading protocols for elbow wear simulation.
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http://dx.doi.org/10.1016/j.jse.2020.03.026DOI Listing
November 2020

Subacromial Balloon Spacer Implantation.

Curr Rev Musculoskelet Med 2020 Oct;13(5):584-591

Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, 3333 North Calvert Street, Suite 400, Baltimore, MD, 21218, USA.

Purpose Of Review: Massive irreparable rotator cuff tears present a treatment challenge for the orthopedic surgeon. There is no gold standard among numerous treatment options including nonoperative management, partial repair, debridement, superior capsular reconstruction, and reverse shoulder arthroplasty. In recent years, yet another option, an implantable biodegradable subacromial balloon spacer has become available with promising early results.

Recent Findings: Biomechanical studies have demonstrated that the balloon spacer effectively restores the normal humeral head position and glenohumeral joint mechanics. This device has been used in Europe since 2012 with promising clinical results. Most of the studies on this implantable balloon represent single surgeon uncontrolled case series with small numbers of patients, but they report improvements in pain and function following spacer placement, with the longest term studies reporting maintenance of improvements for up to 5 years. Certain studies have shown a benefit when the procedure is done in isolation as well as in combination with other arthroscopic procedures, such as partial rotator cuff repair. The balloon subacromial spacer is a promising new device that can be used in the treatment of patients with massive, irreparable rotator cuff tears. In our experience, patients without arthritis who have active forward elevation over 90 degrees and an intact subscapularis have the best chance of a good outcome. We recommend performing the procedure arthroscopically along with any other indicated procedures including debridement, partial repair, and biceps tenotomy or tenodesis. High-quality long-term studies are needed to better define the indications and outcomes of the implantable balloon spacer in the management of irreparable cuff tears.
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http://dx.doi.org/10.1007/s12178-020-09661-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474723PMC
October 2020

Characterizing opioid consumption in the 30-day post-operative period following shoulder surgery: are we over prescribing?

Phys Sportsmed 2021 May 9;49(2):158-164. Epub 2020 Jul 9.

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

: The primary aim of this study was to characterize opioid consumption in the first 30 days after shoulder surgery. Secondary aims were to assess patient expectations, pain tolerance, risk factors for increase opioid consumption, and proper disposal of narcotics.: Patients undergoing rotator cuff repair (RCR), anatomic shoulder arthroplasty, reverse shoulder arthroplasty (RSA), distal clavicle resection, or labral surgery were prospectively enrolled. Collected data included demographics, Pain Catastrophizing Scale (PCS), pain tolerance surveys, narcotic use, adverse effects, and disposal method.: Eighty patients were included in this study. At 28 days, RCR patients took significantly more 5 mg oxycodone-equivalent pills than RSA patients (18.4 vs. 7.5; p = 0.001). Number of days on narcotics did not differ between groups. By day 14, 73 (92.5%) patients had stopped taking narcotics entirely, with 872 5 mg oxycodone-equivalent pills prescribed in surplus. Ten (14.3%) patients required an additional prescription. There was a significant difference in tobacco use (20% vs. 1.4%; p = 0.04), psychiatric history (50% vs. 5.7%; p = 0.0004) and PCS (12.7 vs. 7.1; p = 0.027) in these patients, with PCS of 12.5 as predictive of requiring another prescription.: All patients achieved adequate pain control, with 60 (75%) patients having excess pills. Opioid utilization differed based on surgery - significantly lower use in RSA patients compared to RCR. Only 13 (16.25%) patients required more than 20 5 mg oxycodone-equivalent pills. Tobacco use, history of psychiatric illness, and PCS were risk factors for requiring more prescriptions.
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http://dx.doi.org/10.1080/00913847.2020.1789439DOI Listing
May 2021

Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization.

Orthop J Sports Med 2020 Jun 12;8(6):2325967120924628. Epub 2020 Jun 12.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Background: The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery.

Purpose: To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery.

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

Methods: A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records.

Results: The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups ( = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period ( = .513). There was no difference in postoperative range of motion.

Conclusion: The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.
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http://dx.doi.org/10.1177/2325967120924628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294484PMC
June 2020
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