Publications by authors named "Richard J Friedman"

62 Publications

Increased Perioperative Complication Rates in Patients with Solid Organ Transplants Following Rotator Cuff Repair.

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

Medical University of South Carolina, Department of Orthopaedics, 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 peri-operative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to non-transplanted 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 non-transplant (n=144,242 weighted) cohorts. Demographic and comorbidity analyses was performed between these groups. Additionally, a matched cohort of non-transplanted 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 non-transplanted 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. .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 peri-operative complication (24% vs. 3%, p < .001) with an odds ratio of 7.7 (95% CI: 3.9-15.1).

Conclusion: Compared to non-transplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were over seven times more likely to experience a peri-operative 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.

Level Of Evidence: Level III; Retrospective Cohort Comparison using Large Database; Treatment Study.
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http://dx.doi.org/10.1016/j.jse.2020.12.024DOI Listing
February 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

Anatomic total shoulder arthroplasty after healed rotator cuff repair: a matched cohort.

J Shoulder Elbow Surg 2020 Nov 9;29(11):2221-2228. Epub 2020 Jun 9.

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

Background: Rotator cuff tears are a common cause of failure after anatomic total shoulder arthroplasty (TSA). The purpose of this study was to evaluate the effect of a healed prior rotator cuff repair (RCR) on outcomes and complications after primary TSA. We hypothesized that patients with a prior healed RCR would have equivalent outcomes and complication rates compared with patients without prior surgery.

Methods: A retrospective review of all primary TSAs with a prior RCR was performed using a multicenter database between 2005 and 2017. Thirty shoulders with prior RCR were case matched on a 3:1 ratio with a minimum 2-year follow-up. Range of motion, strength, patient-reported outcome measures, complications, and reoperations were compared.

Results: Thirty shoulders with a prior RCR were compared with 90 control patients without prior surgery at a mean follow-up of 43 months (range, 24-109 months). Groups demonstrated similar preoperative range of motion and patient-reported outcome measures. Postoperatively, TSAs with a prior healed RCR demonstrated less forward flexion (132° vs. 143°, P = .14) and strength (5.7 vs. 6.4 kg, P = .55) compared with control shoulders with no prior surgery; however, these did not meet statistical significance. Complications were significantly more common in patients with a prior RCR (17% vs. 7%, P = .01). Postoperative rotator cuff tears were significantly more common in TSA with a healed prior RCR (13% vs. 1%, P = .014).

Conclusions: TSA after RCR results in similar functional improvements compared with shoulders without prior surgery. However, the risk of a postoperative rotator cuff tear is significantly higher after prior successful RCR. Surgeons should consider this potential complication when indicating these patients for primary TSA.
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http://dx.doi.org/10.1016/j.jse.2020.03.029DOI 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

Preoperative external rotation deficit does not predict poor outcomes or lack of improvement after reverse total shoulder arthroplasty.

J Orthop 2020 Sep-Oct;21:379-383. Epub 2020 Aug 22.

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

Introduction: The purpose was to compare postoperative outcomes and functional improvement between patients with preoperative aER deficits vs. preserved aER function.

Results: There were 115 patients in the <0° aER group and 314 in the ≥30° aER group. Preoperative patients in the <0° group were worse for all measures except subjective pain while post-operatively, they had significantly greater improvement for all measures of motion. Postoperatively, both groups achieved comparable scores for forward elevation, pain, SST and ASES.

Conclusion: This study demonstrates that patients with a complete aER deficit can recover substantial and comparable function after RTSA.
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http://dx.doi.org/10.1016/j.jor.2020.08.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475072PMC
August 2020

Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Apr 4;30(4):811-818. Epub 2020 Aug 4.

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

Background: Complications after anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty can be devastating to a patient's quality of life and require revisions that are costly to both the patient and the health care system. The purpose of this study is to determine the types, incidence, and timing of complications following aTSA and rTSA using an international database of patients who received a single-platform total shoulder arthroplasty system, in order to quantify the types of failure modes and the differences that occur between aTSA and rTSA.

Methods: A total of 2224 aTSA (male-female, 1090:1134) and 4158 rTSA (male-female, 1478:2680) patients were enrolled in an international database of primary shoulder arthroplasty performed by 40 different surgeons in the United States and Europe. Adverse events and revisions reported for these 6382 patients were analyzed to identify the most common failure modes associated for both aTSA and rTSA.

Results: For the 2224 aTSA patients, 239 adverse events were reported for a complication rate of 10.7% and 124 revisions for a revision rate of 5.6%. The top 3 complications for aTSA were rotator cuff tear/subscapularis failure (n = 69; complication rate = 3.1%, revision rate = 1.9%), aseptic glenoid loosening (n = 55; complication rate = 2.5%, revision rate = 1.9%), and infection (n = 28; complication rate = 1.3%, revision rate = 0.8%). For the 4158 rTSA patients, 372 adverse events were reported for a complication rate of 8.9% and 104 revisions for a revision rate of 2.5%. The top 3 complications for rTSA were acromial/scapular fracture/pain (n = 102; complication rate = 2.5%, revision rate = 0.0%), instability (n = 60; complication rate = 1.4%, revision rate = 1.0%), and pain (n = 49; complication rate = 1.2%, revision rate = 0.2%).

Conclusions: This large database analysis quantified complication and revision rates for aTSA and rTSA. We found aTSA and rTSA complication rates of 10.7% and 8.9%, respectively; with revision surgery rates of 5.6% and 2.5%, respectively. The 2 most common complications for each prosthesis type (aTSA: subscapularis/rotator cuff tears, aseptic glenoid loosening; rTSA: acromial/scapular fractures, instability) were unique to each device. The rate of infection was similar for both. Future prosthesis and technique development should work to mitigate these common complication types in order to reduce their rate of occurrence.
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http://dx.doi.org/10.1016/j.jse.2020.07.028DOI Listing
April 2021

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group.

J Shoulder Elbow Surg 2021 Apr 23;30(4):736-746. Epub 2020 Jul 23.

ASES B2 Glenoid Multicenter Research Group.

Background: Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group.

Methods: Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories.

Results: Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87).

Discussion: Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.
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http://dx.doi.org/10.1016/j.jse.2020.07.013DOI Listing
April 2021

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

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

Clinical and radiographic outcomes with a posteriorly augmented glenoid for Walch B glenoids in anatomic total shoulder arthroplasty.

J Shoulder Elbow Surg 2020 May 7;29(5):e185-e195. Epub 2020 Jan 7.

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

Background: Osteoarthritis of the glenohumeral joint is often associated with posterior glenoid wear. The purpose of this study was to determine the clinical and radiographic outcomes of a posteriorly augmented glenoid in patients who have a Walch B glenoid deformity when treated with anatomic total shoulder arthroplasty (aTSA).

Methods: At total of 68 primary aTSA patients with osteoarthritis and a Walch B glenoid deformity were treated with an 8° posteriorly augmented glenoid. All patients were evaluated and underwent scoring preoperatively and at latest follow-up with 5 clinical outcome scoring metrics; active range of motion (ROM) was also measured. The mean follow-up period was 50 months, with a 2-year minimum follow-up period.

Results: All patients experienced significant improvements in pain and function following aTSA with a posteriorly augmented glenoid, and 90% of patients exceeded the minimal clinically important difference threshold for the clinical outcome metric scores and ROM measures. Two-thirds of patients exceeded the substantial clinical benefit threshold for the clinical outcome metrics and ROM. Preoperatively, the humeral head was posteriorly subluxated an average of 73% for each Walch B glenoid type, and at latest follow-up, all humeral heads were re-centered on the posteriorly augmented glenoid. Two patients with augmented glenoids who had Walch B2 glenoids underwent revision for aseptic glenoid loosening.

Discussion: Anatomic total shoulder arthroplasty patients with Walch B glenoids receiving an 8° posteriorly augmented wedge glenoid experienced excellent clinical and radiographic outcomes with a patient satisfaction rate greater than 97% and a low complication rate at a mean follow-up of 50 months. Humeral head centering was maintained for each type of Walch B glenoid.
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http://dx.doi.org/10.1016/j.jse.2019.10.008DOI Listing
May 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

Preoperative parameters that predict postoperative patient-reported outcome measures and range of motion with anatomic and reverse total shoulder arthroplasty.

JSES Open Access 2019 Dec 18;3(4):266-272. Epub 2019 Nov 18.

Exactech, Gainesville, FL, USA.

Background: Preoperative factors that most influence postoperative outcomes of both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are unknown. The purpose of this study was to identify the preoperative parameters that significantly influence postoperative outcomes of aTSA and rTSA.

Methods: The outcomes of 1089 aTSA patients and 1332 rTSA patients (mean follow-up period, 49 months) from an international registry with a single platform system were analyzed. A multiple linear regression model with backward stepwise selection identified the preoperative parameters that were significant predictors of postoperative clinical outcome metric scores and motion measures for both rTSA and aTSA.

Results: For both aTSA and rTSA patients, numerous preoperative parameters that influence postoperative outcomes were identified. Greater postoperative range of motion (ROM) was significantly influenced by greater preoperative ROM. For aTSA, greater postoperative American Shoulder and Elbow Surgeons (ASES) scores were significantly influenced by greater preoperative ASES scores, no history of shoulder surgery, and the presence of greater preoperative active external rotation. For rTSA, greater postoperative ASES scores were significantly influenced by greater preoperative ASES scores, no history of shoulder surgery, no history of tobacco use, less preoperative passive external rotation, and greater preoperative active external rotation.

Conclusions: This study quantified the preoperative predictors of postoperative clinical outcome metric scores and ROM for both aTSA and rTSA. Numerous significant associations were identified, including demographic and comorbidity risk factors. These associations may be helpful for surgeons to consider when counseling patients regarding aTSA versus rTSA and to establish more accurate expectations prior to surgery.
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http://dx.doi.org/10.1016/j.jses.2019.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928272PMC
December 2019

Patient reported outcome measures of bilateral reverse total shoulder arthroplasty compared to bilateral anatomic total shoulder arthroplasty.

J Orthop 2020 Jan-Feb;17:83-86. Epub 2019 Aug 7.

Shoulder and Elbow Surgery, Medical University of South Carolina, Charleston, SC, USA.

The purpose of this study was to compare patient reported functional outcomes following bilateral aTSA vs rTSA. A retrospective review was conducted on twenty-six pateints who underwent staged bilateral aTSA or rTSA, with a minimum of 2 years follow up. Thirteen patients were included in each group, and patient assessed functional outcomes were measured using the PENN Score, ASES, SST, and SF-12. No statistically significant differences were found between the two groups for all functional outcome scores, patient satisfaction, or SF-12. These findings suggest that patients undergoing bilateral rTSA can expect functional outcomes similar to those obtained after bilateral aTSA. None of the authors involved in the work nor any of the author's institutions at any time received payment or services from a third party for any aspect of the submitted work and have no conflicts of interest to disclose.
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http://dx.doi.org/10.1016/j.jor.2019.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919371PMC
August 2019

Patient-reported outcomes of reverse total shoulder arthroplasty: a comparative risk factor analysis of improved versus unimproved cases.

JSES Open Access 2019 Oct 13;3(3):174-178. Epub 2019 Sep 13.

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

Background: The purpose of this study was to compare characteristics of patients who reported to be subjectively unimproved vs. improved after reverse total shoulder arthroplasty.

Methods: Data were derived from a prospective registry of patients who underwent reverse total shoulder arthroplasty with a minimum 2-year follow-up. Patients were asked to rate their subjective satisfaction and then divided into those who were unchanged or worse (unimproved group [UG]) vs. better or much better (improved group [IG]). The groups were compared for differences in demographic characteristics, preoperative factors, functional outcomes, and complications.

Results: There were 1425 patients in the IG and 134 patients in the UG. Patients in the IG were more likely to have a diagnosis of osteoarthritis. Patients in the UG were more likely to have coronary artery disease and diabetes and to have undergone prior surgery. No differences in implant configuration were found between groups. Preoperative measures for patients in the UG were worse for pain and function but not for range of motion. The outcomes in patients in the UG were worse for all postoperative measures, as well as for preoperative-to-postoperative improvement. Of the patients in the UG, 48% continued to have moderate to severe pain postoperatively. The complication rate was significantly higher in the UG.

Discussion: Up to 8.5% of patients rate themselves as unimproved after surgery. These patients are more likely to have certain comorbidities and to have undergone prior surgery. Although outcomes were significantly worse for all measures in the UG, improvement occurred in all measures despite patients subjectively being worse or unchanged. Residual pain and difficulty sleeping play a substantial role in subjective assessment of overall outcome.
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http://dx.doi.org/10.1016/j.jses.2019.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834991PMC
October 2019

Current Controversies in Total Knee Arthroplasty-Part 2.

J Knee Surg 2019 08 2;32(8):703. Epub 2019 Aug 2.

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

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http://dx.doi.org/10.1055/s-0039-1693113DOI Listing
August 2019

Clinical and radiographic comparison of a hybrid cage glenoid to a cemented polyethylene glenoid in anatomic total shoulder arthroplasty.

J Shoulder Elbow Surg 2019 Dec 16;28(12):2308-2316. Epub 2019 Jul 16.

Exactech, Gainesville, FL, USA.

Background: This study reports the clinical and radiographic outcomes of a hybrid cage glenoid compared with an age-matched, sex-matched, and follow-up-matched cohort of cemented all-polyethylene peg glenoids in patients undergoing anatomic total shoulder arthroplasty with 2 years' minimum follow-up.

Materials And Methods: We reviewed 632 primary anatomic total shoulder arthroplasty patients from an international multi-institutional database; 316 patients received hybrid cage glenoids and were matched for age, sex, and follow-up with 316 patients with cemented all-polyethylene peg glenoids. Each cohort received the same humeral component. Scoring was performed in all patients preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range-of-motion measurements. A Student 2-tailed unpaired t test identified differences in outcomes; P < .05 denoted a significant difference.

Results: Cage glenoid patients had significantly lower rates of radiolucent glenoid lines (9.0% vs. 37.6%, P < .0001) and radiolucent humeral lines (3.0% vs. 9.1%, P = .0088) than all-polyethylene peg glenoid patients. In the cage glenoid cohort, 4 cases of aseptic glenoid loosening (1.3%) and 4 cases of articular surface dissociation (1.3%) occurred. In the all-polyethylene peg cohort, 12 cases of aseptic loosening (3.8%) occurred. Cage glenoid patients had a significantly lower revision rate than all-polyethylene peg glenoid patients (2.5% vs. 6.9%, P = .0088).

Conclusion: At 50 months' mean follow-up, cage glenoids demonstrated equally good clinical outcomes to all-polyethylene peg glenoids. Cage glenoids had significantly fewer radiolucent lines around both the glenoid and humeral components and a lower revision rate. Longer-term follow-up is required to confirm these promising short-term results.
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http://dx.doi.org/10.1016/j.jse.2019.04.049DOI Listing
December 2019

Current Controversies in Total Knee Arthroplasty-Part 1.

J Knee Surg 2019 07 2;32(7):589. Epub 2019 Jul 2.

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

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http://dx.doi.org/10.1055/s-0039-1692393DOI Listing
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

Perioperative Care of the TKA Patient.

J Knee Surg 2018 08 17;31(7):593. Epub 2018 Jul 17.

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

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http://dx.doi.org/10.1055/s-0038-1641748DOI Listing
August 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

Are Age and Patient Gender Associated With Different Rates and Magnitudes of Clinical Improvement After Reverse Shoulder Arthroplasty?

Clin Orthop Relat Res 2018 06;476(6):1264-1273

R. J. Friedman, Department of Orthopedic Surgery, Medical University of South Carolina, Charleston, SC, USA E. V. Cheung, Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA P.-H. Flurin, Bordeaux-Merignac Clinic, Bordeaux, France T. Wright, Department of Orthopaedic Surgery, University of Florida, Gainesville, FL, USA R. W. Simovitch, Palm Beach Orthopaedic Institute, Palm Beach Gardens, FL, USA C. Bolch, C.P. Roche, Exactech, Gainesville, FL, USA J. D. Zuckerman, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.

Background: An improved understanding of how gender differences and the natural aging process are associated with differences in clinical improvement in outcome metric scores and ROM measurements after reverse total shoulder arthroplasty (rTSA) may help physicians establish more accurate patient expectations for reducing postoperative pain and improving function.

Questions/purposes: (1) Is gender associated with differences in rTSA outcome scores like the Simple Shoulder Test (SST), the UCLA Shoulder score, the American Shoulder and Elbow Surgeons (ASES) Shoulder score, the Constant Shoulder score, and the Shoulder Pain and Disability Index (SPADI) and ROM? (2) Is age associated with differences in rTSA outcome scores and ROM? (3) What factors are associated with the combined interaction effect between age and gender? (4) At what time point during recovery does most clinical improvement occur, and when is full improvement reached?

Methods: We quantified and analyzed the outcomes of 660 patients (424 women and 236 men; average age, 72 ± 8 years; range, 43-95 years) with cuff tear arthropathy or osteoarthritis and rotator cuff tear who were treated with rTSA by 13 shoulder surgeons from a longitudinally maintained international database using a linear mixed effects statistical model to evaluate the relationship between clinical improvements and gender and patient age. We used five outcome scoring metrics and four ROM assessments to evaluate clinical outcome differences.

Results: When controlling for age, men had better SST scores (mean difference [MD] = 1.41 points [95% confidence interval {CI}, 1.07-1.75], p < 0.001), UCLA scores (MD = 1.76 [95% CI, 1.05-2.47], p < 0.001), Constant scores (MD = 6.70 [95% CI, 4.80-8.59], p < 0.001), ASES scores (MD = 7.58 [95% CI, 5.27-9.89], p < 0.001), SPADI scores (MD = -12.78 [95% CI, -16.28 to -9.28], p < 0.001), abduction (MD = 5.79° [95% CI, 2.74-8.84], p < 0.001), forward flexion (MD = 7.68° [95% CI, 4.15-11.20], p < 0.001), and passive external rotation (MD = 2.81° [95% CI, 0.81-4.8], p = 0.006). When controlling for gender, each 1-year increase in age was associated with an improved ASES score by 0.19 points (95% CI, 0.04-0.34, p = 0.011) and an improved SPADI score by -0.29 points (95% CI, -0.46 to 0.07, p = 0.020). However, each 1-year increase in age was associated with a mean decrease in active abduction by 0.26° (95% CI, -0.46 to 0.07, p = 0.007) and a mean decrease of forward flexion by 0.39° (95% CI, -0.61 to 0.16, p = 0.001). A combined interaction effect between age and gender was found only with active external rotation: in men, younger age was associated with less active external rotation and older age was associated with more active external rotation (β0 [intercept] = 11.029, β1 [slope for age variable] = 0.281, p = 0.009). Conversely, women achieved no difference in active external rotation after rTSA, regardless of age at the time of surgery (β0 [intercept] = 34.135, β1 [slope for age variable] = -0.069, p = 0.009). Finally, 80% of patients achieved full clinical improvement as defined by a plateau in their outcome metric score and 70% of patients achieved full clinical improvement as defined by a plateau in their ROM measurements by 12 months followup regardless of gender or patient age at the time of surgery with most improvement occurring in the first 6 months after rTSA.

Conclusions: Gender and patient age at the time of surgery were associated with some differences in rTSA outcomes. Men had better outcome scores than did women, and older patients had better outcome scores but smaller improvements in function than did younger patients. These results demonstrate rTSA outcomes differ for men and women and for different patient ages at the time of surgery, knowledge of these differences, and also the timing of improvement plateaus in outcome metric scores and ROM measurements can both improve the effectiveness of patient counseling and better establish accurate patient expectations after rTSA.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999.0000000000000270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263575PMC
June 2018

Rate of Improvement in Clinical Outcomes with Anatomic and Reverse Total Shoulder Arthroplasty.

J Bone Joint Surg Am 2017 Nov;99(21):1801-1811

1Palm Beach Orthopaedic Institute, Palm Beach Gardens, Florida 2Medical University of South Carolina, Charleston, South Carolina 3Stanford University, Stanford, California 4Bordeaux-Mérignac Clinic, Mérignac, France 5Department of Orthopaedics, University of Florida, Gainesville, Florida 6Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY 7Exactech, Gainesville, Florida.

Background: This study quantifies the rate of improvement after anatomic and reverse total shoulder arthroplasty; a better understanding of the rate of improvement associated with each prosthesis type may better establish patient expectations for recovery.

Methods: Prospectively collected data on 1,183 patients who underwent either anatomic total shoulder arthroplasty (n = 505) or reverse total shoulder arthroplasty (n = 678) were collected. The Simple Shoulder Test (SST), University of California at Los Angeles (UCLA) Shoulder, American Shoulder and Elbow Surgeons (ASES), Constant, and Shoulder Pain and Disability Index (SPADI) scores, along with range of motion, were recorded preoperatively and at routine postoperative time points. All included patients had a minimum follow-up of 2 years. The rate of improvement of these outcome measures was quantified for patients who underwent anatomic total shoulder arthroplasty and those who underwent reverse total shoulder arthroplasty to compare recovery over time.

Results: In this study, 3,587 visits by 1,183 patients were analyzed and several differences between prosthesis types were noted. Patients who underwent reverse total shoulder arthroplasty experienced larger improvements in the Constant score and active forward flexion, and patients who underwent anatomic total shoulder arthroplasty demonstrated better improvement in external rotation compared with patients who underwent reverse total shoulder arthroplasty at nearly all time points. By 72 months, improvement in flexion and abduction decreased for each prosthesis type, but in particular for reverse total shoulder arthroplasty. Full improvement was achieved by 24 months, although the majority of improvement was achieved in the first 6 months, with all 5 scoring metrics following a similar rate of improvement. The ASES, SPADI, and UCLA Shoulder scores closely mirrored each other in the magnitude of improvement, and the SST score demonstrated the largest improvement and the Constant score demonstrated the smallest improvement for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty.

Conclusions: Both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty reliably result in improved patient outcomes. However, anatomic total shoulder arthroplasty more reliably improves range of motion, particularly external rotation. Most improvement occurs by 6 months, with some additional improvement up to 2 years for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. Although the indications for anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty are substantially different, in addition to the biomechanical differences, the improvement in outcome scores over time can be expected to be very similar. This study is helpful to patients and health-care providers to establish expectations regarding the rate of recovery after total shoulder arthroplasty.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.16.01387DOI Listing
November 2017

Refuting the lipstick sign.

J Shoulder Elbow Surg 2017 Aug 27;26(8):1416-1422. Epub 2017 Mar 27.

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

Background: Arthroscopic examination of the tendon has been described as the "gold standard" for diagnosis of tendinitis of the long head of the biceps (LHB). An arthroscopic finding of an inflamed and hyperemic LHB within the bicipital groove has been described as the "lipstick sign." Studies evaluating direct visualization in diagnosis of LHB tendinitis are lacking.

Methods: During a 1-year period, 363 arthroscopic shoulder procedures were performed, with 16 and 39 patients prospectively selected as positive cases and negative controls, respectively. All positive controls had groove tenderness, positive Speed maneuver, and diagnostic ultrasound-guided bicipital injection. Negative controls had none of these findings. Six surgeons reviewed randomized deidentified arthroscopic pictures of enrolled patients The surgeons were asked whether the images demonstrated LHB tendinitis and if the lipstick sign was present.

Results: Overall sensitivity and specificity were 49% and 66%, respectively, for detecting LHB tendinitis and 64% and 31%, respectively, for erythema. The nonweighted κ score for interobserver reliability ranged from 0.042 to 0.419 (mean, 0.215 ± 0.116) for tendinitis and from 0.486 to 0.835 (mean, 0.680 ± 0.102) for erythema. The nonweighted κ score for intraobserver reliability ranged from 0.264 to 0.854 (mean, 0.615) for tendinitis and from 0.641 to 0.951 (mean, 0.783) for erythema.

Conclusions: The presence of the lipstick sign performed only moderately well in a rigorously designed level III study to evaluate its sensitivity and specificity. There is only fair agreement among participating surgeons in diagnosing LHB tendinitis arthroscopically. Consequently, LHB tendinitis requiring tenodesis remains a clinical diagnosis that should be made before arthroscopic examination.
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http://dx.doi.org/10.1016/j.jse.2017.01.009DOI Listing
August 2017

Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair.

J Shoulder Elbow Surg 2017 Apr 27;26(4):662-668. Epub 2016 Oct 27.

Exactech, Gainesville, FL, USA.

Background: Repair of the subscapularis with reverse total shoulder arthroplasty (rTSA) is controversial. The purpose of this study is to quantify rTSA outcomes in patients with and without subscapularis repair to determine if there is any impact on clinical outcomes.

Methods: Three hundred forty patients received rTSA and had the subscapularis repaired, whereas 251 patients received rTSA and did not have the subscapularis repaired. The patients were scored preoperatively and at latest follow-up using the Simple Shoulder Test; University of California, Los Angeles; American Shoulder and Elbow Surgeons; Constant; and Shoulder Pain and Disability Index metrics. Motion was also measured. Mean follow-up was 37 months.

Results: All patients showed significant improvements in pain and function after treatment with rTSA. For both cohorts, American Shoulder and Elbow Surgeons and Constant scores significantly improved, as did range of motion. The repaired cohort had significantly higher postoperative scores as measured by 4 of the 5 metrics and significantly more internal rotation, whereas the non-repaired cohort had significantly more active abduction and passive external rotation. The complication rate was 7.4% (0% dislocations) for the subscapularis-repaired cohort and 6.8% (1.2% dislocations) for the non-subscapularis-repaired cohort.

Conclusions: Significant clinical improvements were observed for both the subscapularis-repaired and non-repaired cohorts, with some statistical differences observed using a variety of outcome measures. Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models. No difference was noted in the complication or scapular notching rates between cohorts. These clinical results show that rTSA using a lateralized humeral prosthesis delivers reliable clinical improvements with a low risk of instability, regardless of subscapularis repair.
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http://dx.doi.org/10.1016/j.jse.2016.09.027DOI Listing
April 2017

Tranexamic acid decreases blood loss after total shoulder arthroplasty.

J Shoulder Elbow Surg 2016 Apr 2;25(4):614-8. Epub 2015 Dec 2.

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

Background: Tranexamic acid (TXA) significantly decreases blood loss and transfusion rates after total hip and total knee arthroplasty. The purpose of this study was to determine the effects of intravenous TXA on blood loss and patient outcomes after total shoulder arthroplasty (TSA).

Methods: TXA was used in 106 consecutive patients undergoing primary anatomic and reverse TSA with a dose of 20 mg/kg intravenously (TXA group) and compared with the previous consecutive 88 patients without TXA (non-TXA group). All patients had a blood sample drawn for a hemoglobin and hematocrit determination the morning after surgery. Analysis of variance and χ(2) techniques were used to analyze study hypotheses.

Results: Statistically significant differences in both hemoglobin loss (TXA group Δ = 2.13 vs. non-TXA group Δ = 2.63; P = .01) and hematocrit loss (TXA group Δ = 6.4 vs. non-TXA group Δ = 8.14; P < .01) were seen in the TXA group compared with the non-TXA group. In patients receiving TXA, there were statistically significant decreases in the time spent in the recovery room (mean, TXA group 69 minutes vs. non-TXA group 87 minutes; P < .02) and total length of hospitalization (mean, TXA group 1.18 days vs. non-TXA group 1.4 days; P = .01). Two patients in the TXA group received a blood transfusion, whereas 6 patients in the non-TXA group did.

Conclusions: TXA 20 mg/kg intravenously given just before primary anatomic and reverse TSA results in statistically significant reductions in blood loss. Patients spent 21% less time in the recovery room and had a 16% shorter hospitalization, resulting in financial savings for the hospital.
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http://dx.doi.org/10.1016/j.jse.2015.09.014DOI Listing
April 2016

Oral dabigatran etexilate versus enoxaparin for venous thromboembolism prevention after total hip arthroplasty: pooled analysis of two phase 3 randomized trials.

Thromb J 2015 17;13:36. Epub 2015 Nov 17.

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

Background: Two phase 3 trials compared 28-35 days of treatment with oral dabigatran 220 mg or 150 mg (RE-NOVATE) or 220 mg (RE-NOVATE II) once daily with subcutaneous enoxaparin 40 mg once daily for prevention of venous thromboembolism (VTE) after elective total hip arthroplasty.

Methods: This prespecified pooled analysis compared the outcomes for the dabigatran 220 mg dose with enoxaparin, which included 4,374 patients. Total VTE (venographic and symptomatic) plus all-cause mortality (primary efficacy), major VTE (proximal deep vein thrombosis [DVT] or non-fatal pulmonary embolism) plus VTE-related death, and bleeding events were evaluated. Efficacy analysis was based on the modified intention-to-treat (ITT) population and safety analysis was based on all treated patients. The common risk difference (RD) for dabigatran versus enoxaparin was estimated using a fixed effects model.

Results: Total VTE and all-cause mortality occurred in 6.8 % (114/1,672) and 7.7 % (129/1,682) (RD:-0.8 %, 95 % confidence interval [CI] -2.6 to 0.9) for dabigatran and enoxaparin, respectively. Major VTE plus VTE-related mortality occurred in 2.7 % (46/1,714) and 4.0 % (69/1,711) (RD: -1.4 %, 95 % CI -2.6 to -0.2) of patients receiving dabigatran 220 mg and enoxaparin, respectively. Major bleeding occurred in 1.7 % (37/2,156) and 1.3 % (27/2,157) (RD: 0.5 %, 95 % CI -0.2 to 1.2), for dabigatran and enoxaparin respectively.

Conclusions: Extended prophylaxis with oral dabigatran 220 mg once daily was as effective as enoxaparin 40 mg once daily in reducing the risk of total VTE and all-cause mortality after total hip arthroplasty, with a similar bleeding profile. The clinically relevant outcome of major VTE and VTE-related death was significantly reduced with dabigatran versus enoxaparin.

Trial Registration: NCT00657150 and NCT00168818.
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http://dx.doi.org/10.1186/s12959-015-0067-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4647514PMC
November 2015