Study Design:Retrospective cohort study.Objective:The purpose of this study is to determine the utility of advanced imaging to confirm the placement of robotic pedicle screws.Summary of Background Data:With increasing robotic adoption, certain institutions and surgeons have developed protocols for obtaining 3D intraoperative imaging after robotic pedicle screw placement to ensure proper hardware placement. No studies have assessed the utility of these protocols relative to the potential risks of increased radiation exposure and operative time. The purpose of this study is to determine if we should be obtaining advanced imaging to confirm the placement of robotic pedicle screws.Methods:This is a single institution retrospective cohort study of patients from May 2022 to July 2023 who underwent lumbar spinal fusion by a high-volume orthopedic spine surgeon at a level 1 metropolitan hospital. All cases used combined robotics and navigation systems for pedicle screw placement and intraoperative 3D imaging for evaluation of screw position. Pedicle screw accuracy was assessed using the Gertzbein and Robbins system (GRS). Acceptable pedicle screw position was defined as GRS A or B.Results:Seventy patients with 354 robotically placed pedicle screws were assessed with intraoperative 3D fluoroscopy. All pedicle screws were placed in either a GRS type A or type B position. Three hundred fifty-one were placed in a GRS A classification (99.2%, 351/354), and 3 were placed in a GRS B classification (0.08% 3/354). No patients had screw-related complications. The average radiation dosage of 3D imaging was 289.7 +/- 164.6 mGy.Conclusion:The robotic system places pedicle screws accurately without 3D intraoperative imaging. Given the increased radiation and operative time associated with 3D imaging protocols 3D imaging scans should only be obtained in cases with heightened clinical concern.Level of Evidence:Level IV.

Purpose: To quantify cellular senescence in supraspinatus tendon and subacromial bursa of humans with rotator cuff tears and to investigate the in vitro efficacy of the senolytic dasatinib + quercetin (D+Q) to eliminate senescent cells and alter tenogenic differentiation.Methods: Tissue was harvested from 41 patients (mean age, 62 years) undergoing arthroscopic rotator cuff repairs. In part 1 (n = 35), senescence was quantified using immunohistochemistry and gene expression for senescent cell markers (p16 and p21) and the senescence-associated secretory phenotype (SASP) (interleukin [IL] 6, IL-8, matrix metalloproteinase [MMP] 3, monocyte chemoattractant protein [MCP] 1). Senescence was compared between patients <60 and >= 60 years old. In part 2 (n = 6) , an in vitro model of rotator cuff tears was treated with D+Q or control. D+Q, a chemotherapeutic and plant flavanol, respectively, kill senescent cells. Gene expression analysis assessed the ability of D+Q to kill senescent cells and alter markers of tenogenic differentiation.Results: Part 1 revealed an age-dependent significant increase in the relative expression of p21, IL-6, and IL-8 in tendon and p21, p16, IL-6, IL-8, and MMP-3 in bursa (P < .05). A significant increase was seen in immunohistochemical staining of bursa p21 (P = .028). In part 2, D+Q significantly decreased expression of p21, IL-6, and IL-8 in tendon and p21 and IL-8 in bursa (P < .05). Enzyme-linked immunosorbent assay analysis showed decreased release of the SASP (IL-6, MMP-3, MCP-1; P = .002, P = .024, P < .001, respectively). Tendon (P = .022) and bursa (P = .027) treated with D+Q increased the expression of COL1A1.Conclusions: While there was an age-dependent increase in markers of cellular senescence, this relationship was not consistently seen across all markers and tissues. Dasatinib + quercetin had moderate efficacy in decreasing senescence in these tissues and increasing COL1A1 expression.Clinical Relevance: This study reveals that cellular senescence may be a therapeutic target to alter the biological aging of rotator cuffs and identifies D+Q as a potential therapy.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:The purpose of this study is to determine the utility of advanced imaging to confirm the placement of robotic pedicle screws. SUMMARY OF BACKGROUND DATA:With increasing robotic adoption, certain institutions and surgeons have developed protocols for obtaining 3D intraoperative imaging after robotic pedicle screw placement to ensure proper hardware placement. No studies have assessed the utility of these protocols relative to the potential risks of increased radiation exposure and operative time. The purpose of this study is to determine if we should be obtaining advanced imaging to confirm the placement of robotic pedicle screws. METHODS:This is a single institution retrospective cohort study of patients from May 2022 to July 2023 who underwent lumbar spinal fusion by a high-volume orthopedic spine surgeon at a level 1 metropolitan hospital. All cases used combined robotics and navigation systems for pedicle screw placement and intraoperative 3D imaging for evaluation of screw position. Pedicle screw accuracy was assessed using the Gertzbein and Robbins system (GRS). Acceptable pedicle screw position was defined as GRS A or B. RESULTS:Seventy patients with 354 robotically placed pedicle screws were assessed with intraoperative 3D fluoroscopy. All pedicle screws were placed in either a GRS type A or type B position. Three hundred fifty-one were placed in a GRS A classification (99.2%, 351/354), and 3 were placed in a GRS B classification (0.08% 3/354). No patients had screw-related complications. The average radiation dosage of 3D imaging was 289.7±164.6 mGy. CONCLUSION:The robotic system places pedicle screws accurately without 3D intraoperative imaging. Given the increased radiation and operative time associated with 3D imaging protocols 3D imaging scans should only be obtained in cases with heightened clinical concern. LEVEL OF EVIDENCE:Level IV.

Background:Promising short- and midterm outcomes have been seen after anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint (ACJ) injuries. Purpose/Hypothesis:To evaluate long-term outcomes and shoulder-related athletic ability in patients after ACCR for chronic type 3 and 5 ACJ injuries. It was hypothesized that these patients would maintain significant functional improvement and sufficient shoulder-sport ability at a long-term follow-up. Study Design:Case series; Level of evidence, 4. Methods:Included were 19 patients (mean age, 45.9 ± 11.2 years) who underwent ACCR for type 3 or 5 ACJ injuries between January 2003 and August 2014. Functional outcome measures included the American Shoulder and Elbow Surgeons (ASES), Rowe, Constant-Murley, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores as well as the visual analog scale (VAS) for pain, which were collected preoperatively and at the final follow-up. Postoperative shoulder-dependent athletic ability was assessed using the Athletic Shoulder Outcome Scoring System (ASOSS). Shoulder activity level was evaluated using the Shoulder Activity Scale (SAS), while the Subjective Patient Outcome for Return to Sports (SPORTS) score was collected to assess the patients' ability to return to their preinjury sporting activity. Results:The mean follow-up time was 10.1 ± 3.8 years (range, 6.1-18.8 years). Patients achieved significant pre- to postoperative improvements on the ASES (from 54.2 ± 22.6 to 83.5 ± 23.1), Rowe (from 66.6 ± 18.1 to 85.3 ± 19), Constant-Murley (from 64.6 ± 20.9 to 80.2 ± 22.7), SST (from 7.2 ± 3.4 to 10.5 ± 2.7), SANE (from 30.1 ± 23.2 to 83.6 ± 26.3), and VAS pain scores (from 4.7 ± 2.7 to 1.8 ± 2.8) (P < .001 for all), with no significant differences between type 3 and 5 injuries. At the final follow-up, patients achieved an ASOSS of 80.6 ± 32, SAS level of 11.6 ± 5.1, and SPORTS score of 7.3 ± 4.1, with no significant differences between type 3 and 5 injuries. Four patients (21.1%) had postoperative complications. Conclusion:Patients undergoing ACCR using free tendon allografts for chronic type 3 and 5 ACJ injuries maintained significant improvements in functional outcomes at the long-term follow-up and achieved favorable postoperative shoulder-sport ability, activity, and return to preinjury sports participation.

Background: Despite advances in surgical management of acromioclavicular (AC) joint reconstruction, many patients fail to maintain sustained anatomic reduction postoperatively. Purpose: To determine the biomechanical support of the deltoid and trapezius on AC joint stability, focusing on the rotational stability provided by the muscles to posterior and anterior clavicular rotation. A novel technique was attempted to repair the deltoid and trapezius anatomically. Study Design: Controlled laboratory study. Methods: Twelve human cadaveric shoulders (mean ± SD age, 60.25 ± 10.25 years) underwent servohydraulic testing. Shoulders were randomly assigned to undergo serial defects to either the deltoid or trapezius surrounding the AC joint capsule, followed by a combined deltotrapezial muscle defect. Deltotrapezial defects were repaired with an all-suture anchor using an anatomic technique. The torque (N·m) required to rotate the clavicle 20° anterior and 20° posterior was recorded for the following conditions: intact (native), deltoid defect, trapezius defect, combined deltotrapezial defect, and repair. Results: When compared with the native condition, the deltoid defect decreased the torque required to rotate the clavicle 20° posteriorly by 7.1% (P = .206) and 20° anteriorly by 6.1% (P = .002); the trapezial defect decreased the amount of rotational torque posteriorly by 5.3% (P = .079) and anteriorly by 4.9% (P = .032); and the combined deltotrapezial defect decreased the amount of rotational torque posteriorly by 9.9% (P = .002) and anteriorly by 9.4% (P < .001). Anatomic deltotrapezial repair increased posterior rotational torque by 5.3% posteriorly as compared with the combined deltotrapezial defect (P = .001) but failed to increase anterior rotational torque (P > .999). The rotational torque of the repair was significantly lower than the native joint in the posterior (P = .017) and anterior (P < .001) directions. Conclusion: This study demonstrated that the deltoid and trapezius play a role in clavicular rotational stabilization. The proposed anatomic repair improved posterior rotational stability but did not improve anterior rotational stability as compared with the combined deltotrapezial defect; however, neither was restored to native stability. Clinical Relevance: Traumatic or iatrogenic damage to the deltotrapezial fascia and the inability to restore anatomic deltotrapezial attachments to the acromioclavicular joint may contribute to rotational instability. Limiting damage and improving the repair of these muscles should be a consideration during AC reconstruction.

Objective: The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). Summary Background Data: Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. Methods: A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD <= 3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD <= 3 mm. The classification was evaluated in a multi-institutional, international cohort. Results: Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter r3 mm significantly increased CR-POPF risk compared with > 3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively (P < 0.001). Conclusion: For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

3 or 4, respectively).Conclusions Operative treatment of shoulders with preoperative ISP stage 3 or 4 may be risky for occurrence of large retear after performing SCR or patch procedure, thought the two scores were significantly improved at the final follow-up in the two groups.

BackgroundThe COVID-19 pandemic has had global impacts on social interactions and religious activities, leading to a complex relationship between religion and public health policies. This article reviews impact of the COVID-19 pandemic on religious activities and beliefs in relation to the spread of the virus, as well as the potential of religious leaders and faith communities in mitigating the impact of the pandemic through public health measures and community engagement.MethodsA literature review was conducted using PubMed and Google Scholar, with search terms including “religion,” “COVID-19,” “pandemic,” “coronavirus,” and “spirituality.” We included English articles published between January 2020 and September 2022, focusing on intersection of religion and COVID-19.ResultsWe identified two main themes emerging, with the selected 32 studies divided in 15 studies focused on the relationship between religious practices, beliefs, and the spread of COVID-19, while 17 studies explored the role of religious leaders and faith communities in coping with and mitigating the impact of COVID-19. Religious activities were found to correlate with virus spread, particularly in early days of the pandemic. The relationship between religiosity and adherence to government guidelines was mixed, with some studies suggesting increased religiosity contributed to misconceptions about the virus and resistance to restrictions. Religious beliefs were also associated with vaccine hesitancy, particularly conservative religious beliefs. On the other hand, religious leaders and communities played a crucial role in adapting to COVID-19 measures, maintaining a sense of belonging, fostering emotional resilience, and upholding compliance with public health measures. The importance of collaboration between religious leaders, institutions, and public health officials in addressing the pandemic was emphasized.ConclusionsThis review highlights the essential role of religious leaders, faith-based organizations, and faith communities in promoting education, preparedness, and response efforts during the COVID-19 pandemic. Engaging with religious leaders and communities can improve pandemic control and prevention efforts. Collaboration between religious leaders, governments, and healthcare professionals is necessary to combat vaccine hesitancy and ensure successful COVID-19 vaccination campaigns. The insights from this review can guide future research, policy development, and public health interventions to minimize the impact of the pandemic and improve outcomes for individuals and communities affected.

3 or 4, respectively).Conclusions Operative treatment of shoulders with preoperative ISP stage 3 or 4 may be risky for occurrence of large retear after performing SCR or patch procedure, thought the two scores were significantly improved at the final follow-up in the two groups.

3 or 4, respectively).Conclusions Operative treatment of shoulders with preoperative ISP stage 3 or 4 may be risky for occurrence of large retear after performing SCR or patch procedure, thought the two scores were significantly improved at the final follow-up in the two groups.

Objective: To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. Background: POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. Methods: Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014–2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007–2016) to assess discrimination and calibration in an internal-external validation procedure. Results: Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11–1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32–1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78–0.88) and 0.73 (95% CI: 0.70–0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%–25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74–0.85). Conclusions: The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com. The 3 distinct risk groups allow for personalized treatment and benchmarking.

Background: Acromioclavicular joint (ACJ) injuries are common, and many are adequately treated nonoperatively. Biomechanical studies have mainly focused on static ligamentous stabilizers. Few studies have quantified ACJ stabilization provided by the trapezius. Purpose/Hypothesis: To elucidate the stabilization provided by the trapezius to the ACJ during scapular internal and external rotation (protraction and retraction). It was hypothesized that sequential trapezial resection would result in increasing ACJ instability. Study Design: Controlled laboratory study. Methods: A biomechanical approach was pursued, with 10 cadaveric shoulders with the trapezius anatomically force loaded to normal. The trapezius was then serially transected over 8 trials, which alternated between clavicular defects (CD) and scapular defects (SD); each sequential defect consisted of 25% of the clavicular or scapular trapezial attachment. After each defect, specimens were tested with angle-controlled scapular internal and external rotation (12°) with rotary torque measurements to evaluate ACJ stability. Results: The mean resistance in rotary torque for 12° of scapular internal rotation (protraction) with native specimens was 7.0 ± 2.0 N·m. Overall, internal rotation demonstrated a significant decrease in ACJ stability with trapezial injury (P < .001). Eight sequential defects resulted in the following significant percentage decreases in rotary torque from native internal rotation: 1.5% (25% CD; 0% SD), 5.6% (25% CD; 25% SD), 5.1% (50% CD; 25% SD), 6.5% (50% CD; 50% SD), 3.8% (75% CD; 50% SD), 7.1% (75% CD; 75% SD), 6.7% (100% CD; 75% SD), and 12.3% (100% CD 100% SD) (P < .001). The mean resistance in rotary torque for 12° of scapular external rotation (retraction) with native specimens was 7.1 ± 1.7 N·m. External rotation did not demonstrate a significant decrease in ACJ stability with trapezial injury (P = .596). The 8 sequential defects resulted in decreases in rotary torque from native external rotation of 0%, 3.8%, 4.0%, 3.2%, 3.5%, 3.4%, 4.2%, and 0.7%. Conclusion: Trapezial injury resulted in increased instability in the setting of scapular internal rotation (protraction) of the ACJ. Clinical Relevance: These findings validate the inclusion of deltotrapezial fascial injury consideration in the modified Rockwood classification system. Repair of the trapezial insertion on the ACJ may provide improved outcomes in the setting of ACJ reconstruction.

Background: Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesized that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF. Methods: The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003 to 2020. Outcomes were compared between cases utilizing 0, 1, or 2 intraperitoneal drains. Multivariable regression analysis was used to evaluate the optimal drainage approach. Results: A total of 4,292 PDs used 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone cases compared with negligible/low FRS zone cases (13% vs 2.4%, P < .001). The number of drains placed also correlated with FRS zone (median of 2 in intermediate/high vs 1 in negligible/low risk cases). In intermediate/high risk cases, the use of 2 drains instead of 1 was not associated with a reduced rate of CR-POPF, average complication burden attributed to a CR-POPF, reoperations, or mortality. Obviation of drains was associated with significant increases in complication burden and mortality - regardless of the FRS zone. Conclusion: In intermediate/high risk zone cases, placement of a single drain or multiple drains appears to mitigate the complication burden while use of no drains is associated with inferior outcomes. (C) 2021 Elsevier Inc. All rights reserved.

Objectives: Beginning January 1, 2021 total shoulder arthroplasty (TSA) was removed from the Medicare (U.S national healthcare for patients 65years of age) inpatient-only list. Furthermore, there is limited data comparing outpatient and inpatient TSA among recent contemporary large population databases. This study aimed to analyze shoulder arthroplasty outcomes between inpatient and outpatient procedures at the national level. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized (2015???2019). Cases with a current procedural terminology of 23472 indicative of primary TSA and reverse total shoulder arthroplasty were included (N = 22,452). Outcomes were then analyzed in two approaches: unmatched analysis and propensity score matched risk-adjusted analysis. Results: Overall, 9.7% (N = 2,185) of cases were performed outpatient and 90.3% (N = 20,357) of cases were performed inpatient. The rate of outpatient procedures has been steadily increasing (2015: 8.3%, 2016: 14.7%, 2017: 15.8%, 2018: 26.5%, 2019: 34.6%; P < 0.001). Outpatients were more likely to be male (50.7% vs. 43.7%) and younger (age < 65; 37.0% vs. 27.9%) and less likely to be ASA class 3 or 4 (49.5% vs. 58.3%). Outpatients had fewer comorbidities including obesity (46.1% vs. 51.9%), hypertension (60.5% vs. 67.4%), diabetes (15.1 vs. 18.2%), chronic obstructive pulmonary disease (4.8% vs. 7.0%), bleeding disorders (1.3% vs. 2.5%), or chronic steroid use (3.5% vs. 5.0%; all P < 0.001). In a non-risk matched analysis of outcomes, outpatient procedures displayed lower rates of any adverse event (3.5% vs. 5.3%; P < 0.001), minor adverse events (1.5% vs. 3.0%; P = 0.001), and readmission (2.2% vs. 2.8%; P = 0.025). Following a propensity score matched analysis, two risk matched cohorts of outpatient (N = 2,172) and inpatient (N = 2,172) procedures were identified. Subsequent analysis of outcomes revealed no significant differences in outcome metrics between risk-matched outpatient and inpatient procedures. Conclusions: From 2015 to 2019, there has been a four-fold increase in the proportion of outpatient shoulder arthroplasty cases in the ACS-NSQIP database. This study shows that outpatient shoulder arthroplasty may be safely performed in a select cohort of patients without increased risk of adverse events. After adjusting for comorbidities, there were no differences in clinical outcomes or rates of adverse outcomes between inpatient and outpatient shoulder arthroplasty. Level of evidence: Retrospective Observational Study, Level IV.

BACKGROUND:Various distal biceps tendon repair techniques exist, each with their own biomechanical profile. Recently, all-suture anchor fixation has recently become an intriguing option for distal biceps fixation, compared with the proven track record of the suspensory cortical button. In addition, intramedullary techniques have been utilized as a means to avoid complications such as nerve damage seen with extramedullary fixation. PURPOSE:The purpose of this study is to perform a comparative biomechanical analysis of 4 unique distal biceps tendon fixation methods: Unicortical/intramedullary all-suture anchor fixation (UIAS), Bicortical/extramedullary all-suture anchor fixation (BEAS), Unicortical/intramedullary suspensory button fixation (UISB), and Bicortical/extramedullary suspensory button fixation (BESB). STUDY DESIGN:Controlled Laboratory study. METHODS:24 fresh-frozen cadaveric elbows were randomized into 4 groups providing data from 6 specimens, with each group undergoing a different repair technique. The specimens underwent 2 studies: Cyclic loading and Ultimate Load to failure (ULTF) testing. The repaired elbows were cycled 3000 times between 0 and 90 degrees of flexion, with displacement under cyclic loading at the repair site measured using a differential variable reductance transducer. ULTF test was performed with the elbow flexed at 90 degrees. The modes of failure were recorded. RESULTS:The mean cyclic displacements between the 4 groups were as follows: UIAS: 1.45 ± 1.04 mm; BEAS: 2.75 ± 1.32 mm; UISB: 1.45 ± .776 mm; BESB: 2.66 ± 1.18 mm (p= 0.077). Bicortical repairs displayed greater displacement after cyclic loading when compared with unicortical repairs regardless of anchor used (p= 0.007). The mean ULTF for each group was as follows: all-suture intramedullary: 200 N; all-suture extramedullary: 330 N; cortical-button intramedullary: 256 N; cortical-button extramedullary: 342 N). All-suture unicortical/intramedullary repair had a significantly lower ULTF (200 N) compared with cortical-button Bicortical/extramedullary repair (342 N) (p=0.043). CONCLUSION:Bicortical/extramedullary suspensory button fixation demonstrated a greater ultimate load to failure when compared with unicortical/intramedullary all-suture anchor fixation. These findings suggest that bicortical/extramedullary suspensory cortical button fixation is a biomechanically superior construct as compared to unicortical/intramedullary all-suture anchor fixation. However, there was no significant difference in ULTF between extra-medullary, Bicortical button or Bicortical, all-suture anchor fixation.

Purpose:To report the clinical outcomes after biologically augmented rotator cuff repair (RCR) with a fibrin scaffold derived from autologous whole blood and supplemented with concentrated bone marrow aspirate (cBMA) harvested at the proximal humerus.Methods:Patients who underwent arthroscopic RCR with biologic augmentation using a fibrin clot scaffold ("Mega- Clot") containing progenitor cells and growth factors from proximal humerus BMA and autologous whole blood between April 2015 and January 2018 were prospectively followed. Only high-risk patients in primary and revision cases that possessed relevant comorbidities or physically demanding occupation were included. Minimum follow-up for inclusion was 1 year. The visual analog score for pain (VAS), American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), Single Assessment Numerical Evaluation (SANE), and Constant-Murley scores were collected preoperatively and at final follow-up. In vitro analyses of the cBMA and fibrin clot using nucleated cell count, colony forming units, and live/dead assays were used to quantify the substrates.Results:Thirteen patients (56.9 ± 7.7 years) were included. The mean follow-up was 26.9 ± 17.7 months (n = 13). There were significant improvements in all outcome scores from the preoperative to the postoperative state: VAS (5.6 ± 2.5 to 3.1 ± 3.2; P < .001), ASES (42.0 ± 17.1 to 65.5 ± 30.6; P < .001), SST (3.2 ± 2.8 to 6.5 ± 4.7; P = .002), SANE (11.5 ± 15.6 to 50.3 ± 36.5; P < .001), and Constant-Murley (38.9 ± 17.5 to 58.1 ± 26.3; P < .001). Six patients (46%) had retears on postoperative MRI, despite all having improvements in pain and function except one. All failures were chronic rotator cuff tears, and all were revision cases except one (1.6 ± 0.5 previous RCRs). The representative sample of harvested cBMA showed an average of 28.5 ± 9.1 × 106 nucleated cells per mL.Conclusions:Arthroscopic rotator cuff repairs that are biologically augmented with a fibrin scaffold containing growth factors and autologous progenitor cells derived from autologous whole blood and humeral cBMA can improve clinical outcomes in primary, as well as revision cases in high-risk patients. However, the incidence of retears remains a concern in this population, demanding further improvements in biologic augmentation.Level of Evidence:IV, therapeutic case series.

BACKGROUND:Previous studies have demonstrated that online patient educational materials are written at reading levels too advanced for the average patient. The average American reads at the eighth-grade reading level. To date, the readability of online educational material of academic centers for shoulder arthroplasty has not been analyzed.METHODS:Online patient educational materials from the top 25 orthopedic institutions, as ranked by U.S. News & World Report, were assessed utilizing the following readability assessments: Flesch-Kincaid (FK), Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index, Automated Readability Index, FORCAST, and the New Dale and Chall Readability. All of these scores, with the exception of the Flesch Reading Ease, provide an output indicating reading difficulty based on grade level. Correlations between academic institutional ranking and FK scores were evaluated using a Spearman regression. Lastly, additional factors including geographical location, private versus public institution, and use of concomitant multi-media modalities that may impact institutional readability scores (as determined by FK) were evaluated.RESULTS:Only 16.0% of the top 25 institutions included online material at or below the eighth-grade reading level. Moreover, half of the online resources evaluated (those with FK score ≥9.3) were not at a suitable reading level for more than two-thirds of the general United States population (∼70%). Overall, the composite mean scores were 9.5 ± 2.1 for FK, 52.8 ± 9. for 4 Flesch Reading Ease, 12.2 ± 2.4 for Gunning Fog, 11.6 ± 1.8 for Coleman-Liau, 12.3 ± 1.7 for Simple Measure of the Gobbledygook Index, 9.6 ± 2.6 for Automated Readability, 11.1 ± 0.6 for FORCAST, and 5.9 ± 0.6 for New Dale and Chall. There was no correlation between institutional ranking and FK scores (ρ = -0.15; P = .946). Geographical location, private versus public institution, and use of concomitant multi-media modalities were not significantly associated with readability.CONCLUSION:Shoulder arthroplasty online patient educational material at top-ranked orthopedic institutions have poor readability and are likely not suitable for the majority of patients in the United States.

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Introduction:Traumatic shoulder dislocations in elderly patients can result in significant shoulder pathology. Rotator cuff tears and recurrent instability are common complications follow a dislocation event, while axillary nerve injury is less common. While there have been rare cases of recurrent shoulder instability with concomitant axillary nerve injury, there have been no prior cases, in which concurrent fracture fragmentation resulted in the initial gross instability.Case Report:A 68-year-old male with painful gross instability presents following a traumatic dislocation. The patient sustained an axillary nerve injury to the ipsilateral side resulting in a non-functioning deltoid. Pre-operative X-rays showed recurrent chronic glenohumeral dislocation, computerized tomography imaging showed a greater tuberosity fracture, and magnetic resonance imaging showed a massive cuff tear with retraction and atrophy. Given the level of instability and deltoid dysfunction, the patient was treated with shoulder arthrodesis. Intraoperatively, a large fragment of greater tuberosity with ligamentous attachments was found adhered to the anterior glenoid. After arthrodesis, the patient's pain and function improved significantly.Conclusion:When treating elderly patients with gross instability following a traumatic dislocation, surgeons should keep in mind the high likelihood of concomitant avulsion fracture, and that migratory cortical fragments can be a nidus for a patient's instability. When selected for appropriately, these patients can be effectively treated with shoulder arthrodesis with excellent improvements of pain and functionality.