INTRODUCTIONWhile there has been increased attention to the use of reverse total shoulder arthroplasty (RTSA) to treat rotator cuff intact glenohumeral osteoarthritis (RCIOA) for older age groups, there has not been as precise an assessment of the differences in utilization for female versus male patients or in specific age groups. Our purpose was to determine if differences existed in the utilization of shoulder arthroplasty to treat RCIOA based on gender and age in North America.METHODSAnatomic total shoulder arthroplasty (ATSA) and RTSA cases were queried from the American Academy of Orthopaedic Surgeons (AAOS) Shoulder and Elbow Registry (SER) between January 2015 and December 2021. Cases were included if they had a diagnosis of RCIOA, defined by the ICD-10 codes M19.011, M19.012, and M19.019. Cases were stratified by procedure, age, gender, and year of surgery. Chi-square and Fisher’s exact tests were calculated to assess the associations between procedure type and patient demographics.RESULTSThere were 2,748 (48.06%) ATSA and 2,970 (51.94%) RTSA procedures reported to the AAOS SER. There was a significant relationship between procedure type and age group (p<0.001) in that ATSA was utilized more frequently than RTSA for patients ages <70 years old, and this relationship reversed for ages ≥ 70 years old. Female patients were more likely to receive RTSA (p<0.001). When looking at the relationship between procedure type and gender by age group, both genders were more likely to receive ATSA compared to RTSA for age groups 50-59 and 60-69 (p=0.0097 and p=0.0005, respectively) but not for other age groups. For patients ≥ 70 years old, both females and males were more likely to receive RTSA, but this relationship did not reach statistical significance (p=0.1094). For both genders and ages ≥ 70 years old, there was a significant relationship between year and procedure type (p<0.0001) in that RTSA was more commonly utilized in 2017 and onward.DISCUSSION AND CONCLUSIONWhen assessing patients with rotator cuff intact glenohumeral osteoarthritis, the use of ATSA and RTSA was similar, but for patients 50 to 69 years old, for both genders, the use of ATSA was greater. Although RTSA was more commonly used for both genders in the ≥ 70 years old population, this difference was not significant. Interestingly, for both genders, ages ≥ 70 years old, RTSA was significantly more utilized from 2017 onward. This analysis highlights the influence of age and gender in use of ATSA and RTSA.

Objective:The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears. Methods:This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis. Results:A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear. Conclusions:Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients. Level of Evidence:III.

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare.

BACKGROUND:A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort. METHODS:At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery. RESULTS:Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period. CONCLUSIONS:Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period. LEVEL OF EVIDENCE:Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.

After the popularity of reverse total shoulder arthroplasty (rTSA) in Europe, the United States Food and Drug Administration (FDA) cleared the Delta rTSA system (DePuy Inc., Warsaw, IN, USA) for use in late 2003. The original FDA approved indications for rTSA in the United States were limited to a "Grossly rotator cuff deficient joint with severe arthropathy or a previous failed joint replacement with a grossly rotator cuff deficient joint." Surgeons began to use rTSA for many off-label indications: osteoarthritis (OA) without rotator cuff tear (RCT), massive RCT without OA, proximal humerus fractures (PHFx), inflammatory arthritis (IA), and chronic glenohumeral joint dislocation (GHJD). Since 2006, The FDA has approved PHFx as an indication for some but not all reverse implants. The purpose of this study is to evaluate the trends in off-label rTSA use in the American Academy of Orthopaedic Surgeons Shoulder and Elbow Registry (AAOS-SER). All rTSA procedures reported to the AAOS-SER from January 2015 to March 2021 were analyzed. Diagnoses associated with the use of rTSA including RCT arthropathy, OA without RCT, RCT without OA, PHFx, IA, and GHJD were evaluated, and trends were assessed over the data collection period. At the time of data analysis the AAOS-SER contained 3850 cases of rTSA. Only 24.4% of rTSA surgeries were performed for original on-label use (RCT arthropathy). Off-label use of rTSA was seen in 75.6% of cases. When reviewing those rTSA done off-label, the majority (41.4%) were done for OA without RCT. Other off-label rTSA use included 15.1% for RCT without OA, 13% potentially off-label for PHFx, 4.6% for IA, and 1.6% for GHJD. Proportionally, off-label use is increasing over time while on-label use is decreasing. In the AAOS-SER, the majority of rTSA were performed for indications originally considered off-label by the FDA-a trend increasing over time. Some implant manufacturers have expanded indications for rTSA without providing clinical data to support changing FDA approved indications for use. The incremental expansion of indications for use without supportive data, a practice known as predicate creep, is occurring with rTSA. Performing rTSA for off-label indications may create liability risk for surgeons and implant manufacturers. Device manufacturers should formally expand indications of use for rTSA with the FDA to be consistent with published literature and trends.

Background: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. Hypothesis/Purpose: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. Results: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. Conclusion: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. Registration: NCT02075775 (ClinicalTrials.gov identifier).

Rotator cuff disease is extremely common, affecting between 6.8% and 22.4% of the popu-lation over age 40. Tear prevalence, size, likelihood of progression, and retear rates after surgical repair are all related to increasing age. These data suggest that asymptomatic rota-tor cuff tears are a process related to aging, and the description of this as a "tear" may be inaccurate. In addition to age, other nonmodifiable variables related to the presence and progression of rotator cuff tears include male sex, family history, and hand dominance. Smoking and certain disease states (diabetes, hypertension, serum lipid disorders) are potentially modifiable influences on rotator cuff disease. The relationship between symp-toms and the presence of a rotator cuff tear and the progression of a rotator cuff tear are not robust. As fewer than 95% of people with rotator cuff tears come to surgery, the majority of rotator cuff tears are either asymptomatic or mildly symptomatic. Approximately half of existing rotator cuff tears progress over time. Those that progress more rapidly are more likely to have symptoms as the ability to compensate through teres minor hypertrophy and other adaptive mechanisms are exceeded. Both surgery and nonoperative treatments are effective at treating symptoms in patients with rotator cuff disease, but at this time it is not known which treatment is better for which patients. While some authors recommend repair for younger patients with smaller tears, the data on whether this approach can modify the natural history of rotator cuff disease is lacking. Tech Med 31:150978 & COPY; 2023 Elsevier Inc. All reserved.

Background: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. Methods: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. Results: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m(2) was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. Conclusions: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients. (C) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

A 30-year-old male with a remote history of a right shoulder superior labrum anterior to posterior lesion, treated operatively at an outside hospital, presented with a 3-month history of right shoulder pain. Initial shoulder radiographs were performed and appeared to show no abnormality (Fig. 1). His pain continued for another month, and he also developed painful lymphadenopathy. At that point, a noncontrast magnetic resonance imaging (MRI) was obtained (Fig. 2). This showed a destructive lesion in the scapular neck with communication through the articular surface of the glenoid. There was concern for a malignant process, and a positron emission tomography scan and repeat contrast-enhanced MRI were obtained (Figs. 3 and 4). This showed increased uptake in several lymph nodes. An inguinal lymph node biopsy was performed, tissue was sent for histology, and a referral was made to the orthopedic oncology service due to concern for skeletal malignancy. Our orthopedic oncologists did not feel the imaging was consistent with a metastatic process or a primary bone tumor. Due to the patient’s history of previous labral pathology, it was felt to be more consistent with a paralabral cyst or postsurgical changes, and a referral was made to the sports medicine service. Around this time, the initial biopsy histology revealed granulomatous inflammation. Bartonella henselae titers were drawn and found to be significantly elevated, at 1:1280 on July 15, 2021. On the same day that the titers came back positive, he was started on oral rifampin and azithromycin for 4 weeks, until he was taken to the operating room. He remained on these antibiotics for 4 more weeks after surgery, for a total of 8 weeks. Given the combination of lymphadenopathy, elevated B henselae titers, and abnormal appearance of the glenoid lesion on MRI, this was felt to be a case of B henselae osteomyelitis. A computed tomography scan was then ordered for preoperative planning and the decision was made to perform an arthroscopic irrigation and débridement of the glenoid lesion with possible bone grafting (Fig. 5).Figure 2Noncontrast MRI showing lytic lesion in the glenoid neck taken on April 22, 2021. MRI, magnetic resonance imaging.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Precontrast MRI taken on July 8, 2021. MRI, magnetic resonance imaging.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Contrast-enhanced MRI taken on July 8, 2021. MRI, magnetic resonance imaging.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Presurgical CT showing glenoid articular involvement taken on August 16, 2021. CT, computed tomography.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was taken to the operating room and placed in the lateral position with traction on the arm. After sterile prep, the arthroscope was inserted through a posterior portal and cloudy fluid was noted (Fig. 6). This was sent for laboratory analysis but did not return positive for Bartonella titers. Once the camera was inserted, the joint was noted to have extensive synovitis and fibrinous material was noted throughout the joint (Fig. 7). An anterior portal was established, and the capsule was elevated off the anterior glenoid neck, leaving the previous labral repair intact. A curved microfracture awl was used to probe into the cystic area, and purulent material was noted coming from the area of the cyst. This was also collected and sent for laboratory analysis. A drill and curette were then used to débride the cyst (Fig. 8). This material was collected and sent for Warthin-Starry stain, bacterial/fungal culture, and Bartonella polymerase chain reaction (PCR) testing. Bartonella PCR testing from surgical sample (August 24, 2021) was sent out for testing but the test was inconclusive due to the presence of competing inhibitors to the PCR in this specimen. Stains were negative.Figure 7Fibrinous material seen at the entrance of the intraosseous abscess.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Decompressed intraosseous abscess after usage of microfracture awl and drill.View Large Image Figure ViewerDownload Hi-res image Download (PPT) He was then seen in clinic postoperative day 1 and was having no issues. He was given a prescription to begin physical therapy for gentle range of motion. At his second postoperative appointment, 2 weeks later, he noted improving pain and motion. He was continued on oral antibiotics from the infectious disease team. He was seen again at 6 weeks and reported 75% improvement in his symptoms. He did note some persistent pain, and a repeat MRI was ordered to look for recurrence of the lesion. The MRI showed a decrease in the size of the cyst and reduction of surrounding inflammation. He was seen once again at 3 months and reported near-complete resolution of his symptoms. By this time, the patient had finished his course of antibiotics and C-reactive protein/erythrocyte sedimentation rate had normalized. At final follow-up, roughly 6 months later he had no complaints and was back to doing all his previous activities without any discomfort. B henselae is a gram-negative bacteria responsible for cat scratch disease (CSD). An estimated 12,000-22,000 cases per year are diagnosed in the United States, with over 50% of cases involving children under 18 years of age.3Jackson L.A. Perkins B.A. Wenger J.D. Cat scratch disease in the United States: an analysis of three national databases.Am J Public Health. 1993; 83: 1707-1711Crossref PubMed Scopus (258) Google Scholar,9Nelson C.A. Moore A.R. Perea A.E. Mead P.S. Cat scratch disease: U.S. clinicians' experience and knowledge.Zoonoses Public Health. 2018; 65: 67-73https://doi.org/10.1111/zph.12368Crossref PubMed Scopus (17) Google Scholar As the name would imply, the main carrier of B henselae is feral and domesticated cats. The bacteria is transmitted between cats via fleas and ticks.8Margileth A.M. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature.Pediatr Infect Dis J. 1992; 11: 474-478Crossref PubMed Scopus (282) Google Scholar Infection in humans typically occurs through cat bites, scratches, or saliva coming in contact with open wounds. Contact with cats, most often kittens, is reported in 99% of cases, and a site of inoculation is reported 92% of the time.1Carithers H.A. Cat-scratch disease. An overview based on a study of 1,200 patients.Am J Dis Child. 1985; 139: 1124-1133Crossref PubMed Scopus (550) Google Scholar On chart review there was no prior history of exposure to cats, the well-recognized host. Yet, approximately 5 months prior to his presentation with shoulder pain, the patient sustained open fractures to his 2nd-5th toes from a horse stepping on his bare foot. Although not the typical host, horses have been shown to be asymptomatic carriers of B henselae and this could have seeded an infection.4Jones S.L. Maggi R. Shuler J. Alward A. Breitschwerdt E.B. Detection of Bartonella henselae in the blood of 2 adult horses.J Vet Intern Med. 2008; 22: 495-498https://doi.org/10.1111/j.1939-1676.2008.0043.xCrossref PubMed Scopus (27) Google Scholar The most common symptoms include fever, lymphadenopathy, and a pustule at the site of a scratch.5Klotz S.A. Ianas V. Elliott S.P. Cat-scratch disease.Am Fam Physician. 2011; 83: 152-155PubMed Google Scholar In 80%-90% of cases CSD is self-limiting and resolves without treatment in 2-4 weeks; however, in rare cases disseminated disease occurs and may warrant treatment with antibiotics or surgical intervention.5Klotz S.A. Ianas V. Elliott S.P. Cat-scratch disease.Am Fam Physician. 2011; 83: 152-155PubMed Google Scholar Diagnosis of CSD remains difficult. Culture of the organism is unreliable and may take up to 40 days to show growth.11Schutze G.E. Diagnosis and treatment of Bartonella henselae infections.Pediatr Infect Dis J. 2000; 19: 1185-1187Crossref PubMed Scopus (37) Google Scholar Therefore, if taking cultures, holding them for up to 6 weeks is recommended. Alternatively, if a lymph node or other tissue is removed, it can be examined histologically using a Warthin-Starry silver impregnated stain.10Regnery R. Tappero J. Unraveling mysteries associated with cat-scratch disease, bacillary angiomatosis, and related syndromes.Emerg Infect Dis. 1995; 1: 16-21Crossref PubMed Google Scholar In this case, the intraoperative cultures did not grow B henselae. The patient had been on antibiotics for several weeks before operative intervention, and even in the most ideal situations, the organism is difficult to culture. However, the most effective and widely used way to diagnose CSD is with serologic testing for antibodies against B henselae using enzyme immunoassay or indirect fluorescence method.6Litwin C.M. Martins T.B. Hill H.R. Immunologic response to Bartonella henselae as determined by enzyme immunoassay and Western blot analysis.Am J Clin Pathol. 1997; 108: 202-209Crossref PubMed Scopus (38) Google Scholar This patient did have positive titers, as well as the classic lymphadenopathy associated with CSD. Although uncomplicated CSD does not require any treatment other than supportive measures, azithromycin has been shown in a prospective double-blinded trial to hasten the resolution of lymphadenopathy, without significant long-term differences between placebo. Significantly less data exist on the best treatment for disseminated disease; however, rifampin, ciprofloxacin, trimethoprim-sulfamethoxazole, and gentamicin are all effective in treating disseminated disease.8Margileth A.M. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature.Pediatr Infect Dis J. 1992; 11: 474-478Crossref PubMed Scopus (282) Google Scholar B henselae osteomyelitis has been reported in the literature, although it is exceedingly rare. One series of 1200 patients reported just 2 (0.17%) with osteolytic lesions.1Carithers H.A. Cat-scratch disease. An overview based on a study of 1,200 patients.Am J Dis Child. 1985; 139: 1124-1133Crossref PubMed Scopus (550) Google Scholar Another series of 1852 patients reported just 5 (0.27%) with osseous involvement.7Margileth A.M. Dermatologic manifestations and update of cat scratch disease.Pediatr Dermatol. 1988; 5: 1-9Crossref PubMed Scopus (34) Google Scholar The vertebral column and pelvic girdle make up nearly 70% of reported osseous lesions.2Hajjaji N. Hocqueloux L. Kerdraon R. Bret L. Bone infection in cat-scratch disease: a review of the literature.J Infect. 2007; 54: 417-421https://doi.org/10.1016/j.jinf.2006.10.045Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar To our knowledge, there has never been a case report of B henselae osteomyelitis in the scapula. Although B henselae associated osteomyelitis can resolve with time and antibiotics, there are a few reports of operatively treated B henselae osteomyelitis.12Tasher D. Armarnik E. Mizrahi A. Liat B.S. Constantini S. Grisaru-Soen G. Cat scratch disease with cervical vertebral osteomyelitis and spinal epidural abscess.Pediatr Infect Dis J. 2009; 28: 848-850https://doi.org/10.1097/INF.0b013e3181a3242eCrossref PubMed Scopus (24) Google Scholar,13Vermeulen M.J. Rutten G.J. Verhagen I. Peeters M.F. van Dijken P.J. Transient paresis associated with cat-scratch disease: case report and literature review of vertebral osteomyelitis caused by Bartonella henselae.Pediatr Infect Dis J. 2006; 25: 1177-1181https://doi.org/10.1097/01.inf.0000246807.14916.d3Crossref PubMed Scopus (26) Google Scholar These were most often in the spine, and due to concern for cord compression from an associated abscess. We elected to operatively treat this patient with arthroscopic irrigation and débridement due to the concern for continued articular cartilage damage from the osseous lesion, which had already begun to penetrate through the glenoid into the shoulder joint. We were concerned that antibiotic treatment would not work quickly enough and being a young, active male, we did not want the patient’s articular cartilage to be damaged. B henselae osteomyelitis is a rare presentation of an otherwise self-limiting disease. It should be included in the differential diagnosis of a patient with tender lymphadenopathy and history of close exposure with cats. Biopsy of the inflamed lymph nodes may show granulomatous inflammation, and the diagnosis can be confirmed with serological testing. Uncomplicated cases can be treated with supportive measures, whereas disseminated cases may need antibiotics or operative treatment for resolution of symptoms. In this case report, we present the only known case of B henselae scapular osteomyelitis. More research needs to be performed to determine the best treatment options for osseous involvement of B henselae osteomyelitis.

Category: Other Introduction/Purpose: Unsolicited patient complaints (UPCs) about surgeons have been shown to correlate with surgical complications and malpractice claims in several specialties. Analysis of UPCs in orthopaedics is limited and using large national databases of UPCs may prove informative to orthopaedic providers and administrators. Our purpose was to 1) Evaluate the differences in the number and distribution of UPCs between orthopaedic surgeons as compared to other surgeons, and non- surgeons. 2) Describe the distribution of UPCs among orthopaedic sub-specialties. 3) Assess for clinical characteristics that may be associated with UPCs. Methods: Patient complaint reports recorded at 36 medical centers between January 1st, 2015 through December 31st, 2018 were coded using a previously validated coding algorithm, PARS ® (Patient Advocacy Reporting System ® ). We (1) evaluated the distribution of UPCs across orthopaedic surgeons, (2) compared orthopaedic surgeons’ UPC distribution with those of other surgeons and non-surgeons, and (3) analyzed differences in complaint types across orthopaedic sub-specialties. Results: A total of 33,174 physicians had four consecutive years of data across the 36 nation-wide participating medical centers and met other inclusion criteria, including 1,148 orthopaedic surgeons, 6,747 other surgeons, and 25,279 non-surgeons. Orthopaedic surgeons experienced more UPCs per physician than non-orthopaedic surgeons and non-surgeons (5 vs. 2 vs. 1 respectively, p<0.05); the top 20% of orthopaedic surgeons with UPCs accounted for half of all complaints about orthopaedic surgeons received by the organizations in the study. The sub-specialties that had significantly more UPCs compared to general orthopaedic surgeons were Foot and Ankle (OR 2.6 [1.4-4.6], p=.002), followed by Adult Reconstruction (OR 2.2 [1.3-3.8], p=.002), Spine [OR 2.2 (1.3-3.8), p=.005), and Trauma (OR 2.2 [1.2-4.0], p =.01). Surgeons in the midwest were less likely to get complaints that surgeons in the northeast and sex was not a predicting factor. Conclusion: Orthopaedic surgeons receive comparatively more UPCs than other surgical and non-surgical specialties. Among orthopaedic surgeons, the subspecialties of Foot and Ankle, Adult, Reconstruction, Spine, and Trauma received the most UPCs. As increased UPCs have been linked to higher risk of malpractice claims, individual orthopaedic surgeons with high numbers of UPCs may benefit from being made aware of their elevated risk status in ways that invite reflection on underlying causes.

PURPOSE:To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS:After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS:Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE:I, prognostic study.

Objective Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain. Design From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression. Results In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02–1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16–3.52), and a higher body mass index (per 1 kg/m2: odds ratio = 1.06, 95% confidence interval = 1.03–1.12) were independently associated with rotator cuff tears. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear. Conclusions In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Identify factors associated with an increased risk of developing rotator cuff tears in adults; (2) Describe the current epidemiological trends of rotator cuff tears in the United States; and (3) Discuss the pathophysiological role of aging in the development of nontraumatic rotator cuff tears. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

BACKGROUND:Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing 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 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 transfer. 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 6 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 when 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 treatment 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 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related 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.

Objective: Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain. Design: From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression. Results: In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02-1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16-3.52), and a higher body mass index (per 1 kg/m(2): odds ratio = 1.06, 95% confidence interval = 1.03-1.12) were independently associated with rotator cuff teats. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear. Conclusions: In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research.

Background: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. Purpose: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports. Results: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02). Conclusion: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

Background: Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear. Hypothesis: We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort were analyzed. Patients aged 12 to 99 years undergoing primary surgical treatment for shoulder instability were included. The glenohumeral joint was evaluated by the treating surgeon at the time of surgery, and patients were classified as having a BCL if they had any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of the number of instability events on the presence of BCLs was investigated by use of Fisher exact tests. Logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as P < .05. Results: We identified 271 patients (223 male) for analysis. Bone and cartilage lesions were identified in 54 patients (19.9%) at the time of surgical treatment. A glenoid cartilage injury was most common and was identified in 28 patients (10.3%). A significant difference was noted between the number of instability events and the presence of BCLs (P = .025), with the highest rate observed in patients with 2 to 5 instability events (32.3%). Multivariate logistic regression modeling indicated that increasing age (P = .019) and 2 to 5 reported instability events (P = .001) were significant independent predictors of the presence of BCLs. For bone lesions alone, the number of instability events was the only significant independent predictor; increased risk of bone lesion was present for patients with 1 instability event (OR, 6.1; P = .012), patients with 2 to 5 instability events (OR, 4.2; P = .033), and patients with more than 5 instability events (OR, 6.0; P = .011). Conclusion: Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.

Background: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty. Purpose/Hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures. Study Design: Cross-sectional study; Level of evidence, 3. Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain. Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; P < .001) and were more likely to be female (25.3% vs 17.4%; P = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) ( P < .001), more frequent depression (22.2% vs 8.3%; P < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) ( P < .01), and worse preoperative expectations ( P < .01). Conclusion: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient’s preoperative state but also postoperative pain control and/or postoperative outcomes.