Background:This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients. Methods:Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies. Results:For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001). Conclusion:Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients. Level of Evidence:3.

PURPOSE:To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating neuromuscular and clinical outcomes of blood flow restriction (BFR) training after anterior cruciate ligament reconstruction (ACLR) compared with non-BFR rehabilitation protocols. METHODS:A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic reviews and Meta Analyses guidelines by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials databases from inception through December 2023 to identify Level I and II RCTs evaluating outcomes of BFR training after ACLR compared with non-BFR rehabilitation. A meta-analysis was performed using random-effects models with standardized mean difference (SMD) for pain, muscle strength, and muscle volume, whereas mean difference was calculated for patient-reported outcome measures. RESULTS:Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation compared with 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with most patients being male (63.3%, n = 138/218). The length of the BFR rehabilitation protocol was most commonly between 8 and 12 weeks (range, 14 days to 16 weeks). Most studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared with non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, P = .02, I2: 58%), International Knee Documentation Committee score (mean difference: 10.97, P ≤ .00001, I2: 77%), and pain (SMD: 1.52, P = .04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, P = .43, I2: 76%). CONCLUSIONS:The use of BFR after ACLR led to improvements in pain, International Knee Documentation Committee score, and isokinetic muscle strength, with variable outcomes on the basis of quadriceps strength, volume, and thickness when compared with non-BFR rehabilitation. LEVEL OF EVIDENCE:Level II, systematic review and meta-analysis of Level I and II studies.

Symptomatic acetabular impingement represents a distinct subgroup of patients with femoroacetabular impingement syndrome (FAIS). Acetabular-based impingement, or pincer-type FAIS, is characterized by anterior acetabular over-coverage. Pincer subtypes include focal anterior over-coverage, global anterior over-coverage, relative anterior over-coverage (acetabular retroversion), and anterior inferior iliac spine (AIIS) or subspine impingement. These morphological variants can cause abnormal contact between the acetabulum and the femoral head-neck junction during functional hip motion, leading to a variety of labral and chondral injuries. Diagnosis of pincer-type FAIS requires a thorough history and physical exam as well dedicated imaging, and these aspects should all corroborate the symptoms and diagnosis. When symptoms are refractory to conservative management, surgery should be considered with the approach tailored to the individual patient's specific morphology and pathology. Both open and arthroscopic techniques have been shown to be safe and effective in patients with pincer-type FAIS when patients are appropriately indicated and with careful preoperative planning and surgical execution.

Tennis and other racket sports remain popular among active patients considering shoulder arthroplasty. While the ability to return to tennis following hip and knee arthroplasty has been previously studied, the capacity to participate following shoulder arthroplasty is less well known, especially following reverse shoulder arthroplasty (RSA), which alters shoulder kinematics. The purpose of this study is to characterize the return to racket sports following both total shoulder arthroplasty (TSA) and RSA. The secondary objectives were to evaluate: 1) performance; 2) change in patient-reported outcome measures; 3) range of motion (ROM); and 4) satisfaction of patients who returned to racket sports after TSA. This is a retrospective cohort study of 43 patients identified as playing a racket sport before undergoing either anatomic TSA or RSA. All patients were cleared to return to racket sports activities beginning 3 months following surgery. Patients were contacted by phone or email and a racket sport-specific questionnaire was administered, focusing on their experience returning to racket sports. The results following TSA were compared with those who received RSA. The median age at surgery was 71 (66-75) years, with 26 TSA and 13 RSA patients. Of the 43 patients, 90% were able to return to sport, 4 (3 RSA, 1 TSA) stated that they were unable to return due to a shoulder-related complaint. Of the 39 patients still playing, 19 (49%) returned within 6 months and 33 (85%) returned within 12 months, with no differences among cohorts (P = .344). Overall perceived performance following surgery stayed the same or improved in 90% of the patients. Similarly, overall enjoyment of racket sports either improved or stayed the same in 98% of patients. Pain experienced during sport improved significantly from a median Visual Analogy Scale pain score of 5-0 (P < .001) with no significant difference seen when comparing RSA and TSA. The dominant arm was treated in 14 (54%) TSA and 8 (62%) RSA patients with minimal impact on outcomes. Return to racket sports following both reverse and anatomic TSA is a realistic expectation, along with significant improvements in both pain and sport-specific function while playing. Patients treated with anatomic and RSA can expect similar recovery and racket sport experiences following surgery, with no significant differences between either surgery.

Background: End-stage glenohumeral joint arthritis is common in patients with inflammatory arthritis. Reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (TSA) are both indicated in this setting. RSA is often considered based on the impacts of long-standing inflammatory arthritis including glenoid and humeral bone erosion and rotator cuff insufficiency. However, acromial and scapular spine fractures following RSA have been reported more commonly in these patients, which can have a significant impact on outcomes. Currently, no study has directly compared the efficacy and complication rates of RSA vs. TSA in patients with inflammatory arthritis. This study aimed to investigate differences in clinical outcomes and complications in patients undergoing RSA vs. TSA with glenohumeral inflammatory arthritis. Methods: We performed a retrospective review of 86 patients with inflammatory arthritis treated with primary RSA (n = 43) or TSA (n = 43) with a minimum of 2 years' follow-up. American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, visual analog scale scores for pain and function, active range of motion, and patient self-ratings of upper-extremity normality (Subjective Assessment of Normal Evaluation [SANE]) were collected preoperatively and at minimum 2-year follow-up. Radiographic classification of preoperative glenoid and humeral bone loss was performed, and postoperative complications were observed. Revision and compliResults: The study cohort had an average age of 72.1 years (range, 31-92 years) and average follow-up period of 51.6 months (range, 22-159 months). Both the RSA and TSA cohorts demonstrated improvements in patient-reported outcome measures and ranges of motion; however, patients treated with TSA showed a greater postoperative final Simple Shoulder Test score (P < .001), visual analog scale score for function (P = .0347), active elevation (P = .0331), active external rotation (P < .001), active internal rotation (P = .005), and Single Assessment Numeric Evaluation (SANE) score (P = .0161). Analysis of complication rates demonstrated no statistically significant difference between cohorts. Four acromial fractures occurred in the RSA group. When RSA patients who sustained acromial fractures were removed from the analysis, there were minimal differences in outcomes between the RSA and TSA cohorts. Conclusion: TSA in patients with inflammatory arthritis leads to improved clinical outcomes but higher early revision rates when compared with RSA. RSA outcomes are negatively impacted by a high rate of postoperative acromial fractures. Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study (c) 2022 Journal of Shoulder and Elbow Board of Trustees. All reserved.

Early discharge has been a target of cost-control efforts given the growing demand for joint replacement surgeries. A multisystem medically-based risk-assessment tool known as the Outpatient Arthroplasty Risk Assessment (OARA) score has shown high predictive ability for safe early discharge following an outpatient lower extremity arthroplasty utilizing a score threshold ≤79. Shoulder arthroplasties have been shown to have lower associated medical risks than lower extremity arthroplasties. An OARA score threshold of 110 was recently shown to be safe for same-day discharge (SDD) following shoulder arthroplasties in a series of 422 patients. The purpose of this study is to re-examine the OARA score threshold for shoulder arthroplasties by evaluating its effectiveness in selecting patients for SDD utilizing a larger population of patients. We hypothesize that the OARA score threshold for shoulder arthroplasty will remain higher than the established threshold for lower-extremity arthroplasty. A retrospective review was performed on 734 consecutive patients who underwent a primary anatomic or reverse total shoulder arthroplasty between April 2018 and December 2020 by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room and urgent care visits were obtained from medical records. Analysis of variance testing, Chi-square testing, and screening test characteristics compared the performance of OARA scores to that of the American Society of Anesthesiologists Physical Status. A receiver operating characteristic analysis was completed to determine the optimal OARA score threshold for safe SDD. The receiver operating characteristic analysis showed that 102.5 was the optimal preoperative OARA score threshold for safe SDD following a shoulder arthroplasty. The OARA score cutoff of ≤102.5 points demonstrated a sensitivity of 87.0% for identifying SDD patients. OARA scores ≤102.5 also showed a negative predictive value of 80.6% but remained incomprehensive with a specificity of 28.5% (P < .0001) and a positive predictive value of 39.2. Patients with OARA scores ≤102.5 were over 4 times less likely to have a 90-day emergency room visit (P < .001) than those with scores >102.5. There was no difference in 30-day and 90-day readmission rates for patients with OARA scores ≤102.5, ≤110, and ≤79 and American Society of Anesthesiologists Physical Status ≤2. A preoperative OARA score threshold of ≤102.5 is effective and conservative in screening patients for SDD following a shoulder arthroplasty, with low rates of 90-day emergency room visits and readmissions. This threshold is a useful screening tool to identify patients that are not good candidates for SDD.

Background: Sleep disturbance is commonly reported by patients with arthritis and rotator cuff disease. Small cohort studies have demonstrated sleep improvements following anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). However, to our knowledge, no large cohort study has evaluated sleep improvement after shoulder arthroplasty. The purpose of the present study was to determine the effects of shoulder arthroplasty on sleep improvement, including the speed of sleep recovery, improvement plateaus, and any differences observed between TSA and RSA. Methods: A retrospective analysis of our institution’s shoulder and elbow repository evaluated patients who had been managed with TSA and RSA between 2012 and 2021. Our analysis focused on visual analog scale (VAS) pain scores as well as specific sleep-related questions included in the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) questionnaires. Preoperative characteristics were compared, and comparisons at the 3-month, 6-month, 1-year, and most recent follow-ups were performed to evaluate the efficacy of improvement, speed of recovery, improvement plateaus, and differences among implant types. Results: Our search identified 1,405 patients who were treated with shoulder arthroplasty, including 698 who underwent TSA and 707 who underwent RSA. Six hundred and seventy-six (97%) of those who underwent TSA and 670 (95%) of those who underwent RSA reported sleep disturbance prior to surgery and were eligible for inclusion. With the exclusion of 357 patients without complete follow-up, 989 patients (517 who underwent TSA and 472 who underwent RSA) met the inclusion criteria, with a median follow-up of 36 months for the TSA group and 25 months for the RSA group. Postoperatively, significant improvements in the ability to sleep comfortably and sleep on the affected side were observed in both the TSA group and the RSA group (p < 0.001). The ability to sleep comfortably returned faster than the ability to sleep on the affected side, with the ability to sleep comfortably reaching a plateau at 3 months and the ability to sleep on the affected side reaching a plateau at 6 months. Despite improvements in terms of sleep disturbance, at the time of most recent follow-up, 13.2% of patients in the TSA group and 16.0% of those in the RSA group could not sleep comfortably and 31.4% of those in the TSA group and 36.8% of those in the RSA group could not sleep on the operative side. Conclusions: The results of the study demonstrated that both TSA and RSA provide significant and rapid improvement in patients’ ability to sleep comfortably and, to a lesser extent, improves their ability to sleep on their affected side. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:Early discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD.Methods:A retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer's exact were performed where appropriate.Results:The 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups.Conclusion:Our study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon's practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty.Level of evidence:Level III; Retrospective Comparative Study.

INTRODUCTION:Lesser tuberosity osteotomy (LTO) and subscapularis peel (Peel) are 2 common techniques used to mobilize the subscapularis tendon during anatomic total shoulder arthroplasty (TSA). The literature is inconclusive over which technique is optimal; thus, controversy exists over which technique should be performed. The purpose of this study was to compare specific functional internal rotation tasks and general outcome scores in TSA patients who received either an LTO or Peel. METHODS:A retrospective review of 563 patients treated with primary TSA using either an LTO (n = 358) or Peel (n = 205) with a minimum 2-year follow-up was performed. Subjective internal rotation, active internal rotation, and specific questions related to functional internal rotation isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons functional questionnaires were reviewed. Other outcome scores including visual analog scale pain and function, Single Assessment Numerical Evaluation, SST, American Shoulder and Elbow Surgeons, and revision rates were compared between the 2 groups. RESULTS:The study found no difference in postoperative functional internal rotation and range of motion between LTO and Peel. Patients who received a Peel were shown to have a slightly greater improvement in the ability to perform toileting and a higher average change in SST score that did not reach clinical significance. There was no difference in the percentage of maximal improvement, revision rate, or need for revision between the 2 groups. CONCLUSION:No difference was found between the LTO and Peel techniques in regard to functional tasks of internal rotation at short-term follow-up.

With the evolving nature of the business world, it has become a modern necessity to have a diverse workforce. As such, human resources professionals and managers must be prepared for the redesign of their organizations to be more inclusive throughout their formal hierarchies. Although the overall attitudes have become generally more feminist, the unfortunate reality is that women continue to face internal and external barriers which act as a ceiling to their career development and advancement. Rather than viewing the paucity of women in management positions as a problem because of public disdain towards gender disparities within the workplace, this paper emphasizes that organizations should view this as an opportunity to gain a competitive advantage, given that having more women in leadership positions is correlated to improved organizational performance. The main argument of this research is that gender diversity can lead to better outcomes for an organization; in addition to this, research demonstrates that the inclusion of more women within management positions may also encourage a transformational leadership style, which could potentially lead to sustainable growth for a company. Throughout this paper, using the methodology of reviewing recently published literature, this paper demonstrates the fact that the glass ceiling is detrimental to the economic development of both women and the companies as institutional barriers seem to persistently block them from equitable advancement opportunities. Using published data and expert analysis, we provide suggestions and recommendations for the creation of an inclusive work environment where all employees can have fair and transparent progress based on their goals and qualifications. The “glass ceiling” literature has empirically demonstrated that managers can reduce the negative gender-based stereotypes by empowering more qualified women to take on leadership responsibilities. At the meantime, professionals can serve as advocates in their local governments to create and change laws that are unfair and unjust. All local leaders, managers and employees must promote the benefits of diversity to build and encourage inclusion in the workplace. Furthermore, all organizations can improve their inclusion training so their employees can keep an open mind regarding diversity. With the application of the recommended skills and suggestions, coupled along with public awareness and advocacy for equity in hiring and promotion decisions, the “glass ceiling” can certainly be eliminated in all organizational settings. Keywords: glass ceiling, discrimination, wage gap, inclusion, gender equality, mentoring, and career development.