The pathoanatomy of anterior glenohumeral dislocations in elderly patients is different from those in younger patients in that rotator cuff tears, large glenoid fractures, and peripheral nerve injury are more common. In addition, decision making is made more complex by the wide spectrum of preexisting degenerative pathology, functional demands, and social considerations, such as arthritis, chronic rotator cuff tears, and upper extremity demand for ambulation. Many patients with a first-time dislocation can be treated conservatively with a brief period of immobilization followed by physical rehabilitation. Rotator cuff repair is advisable for most active patients with symptomatic, acute tears. Capsulolabral repairs can be considered for similarly active patients with recurrent instability. Fixation of large glenoid fractures should be considered for patients with displaced fragments >25% of the glenoid width and/or demonstrating humeral subluxation through the fragment if there is adequate bone quality and healing potential. Reverse shoulder arthroplasty plays a large role in managing recurrent instability in patients with limited potential for soft-tissue or bone healing, inability to comply with soft-tissue repair postoperative protocols, and preexisting degenerative changes.

Background:This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality.Methods:Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys.Results:The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8).Discussion:The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management.Conclusion:This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality.

Background: Minimal data is available on the accuracy of diagnoses for orthopaedic shoulder complaints developed via telemedicine consultations. We hypothesize that evaluating surgeons can accurately diagnose and treat shoulder pathology via telemedicine evaluation. Methods: Patient evaluations for new shoulder complaints via telemedicine were retrospectively reviewed. Records were kept of all new patients seen via telemedicine, and all patients were advised to follow-up for in-person evaluation. All patients with in-person follow-up were included in final analysis. Changes in diagnosis or treatments were noted at time of in-person evaluation. Results: Eighty-two patients completed both telemedicine and in-person evaluation. 44 (53.6%) had no changes in diagnosis or treatment, and 22 (26.8%) had no change in diagnosis with advancement in treatment. Sixteen patients (19.5%) had a change in diagnosis or treatment. Of the 16 patients where changes were made, 9 patients were given additional diagnoses, and 7 patients had changes in their diagnosis at time of in-person follow-up. Two (2.4%) patients had a change in treatment resulting from the in-person visit. Fifty-seven patients (69.5%) had imaging (X-ray, MRI, or CT) available during the telemedicine visit. Conclusions: Telemedicine was an effective platform for evaluating patients with new shoulder complaints, with only 2.4% of treatments altered after in-person evaluation. There may be specific shoulder pathology that is more difficult to diagnose via telemedicine or without advanced imaging. Further research evaluating patient and surgeon satisfaction with telemedicine is underway. Level of Evidence: IV, Retrospective Cohort Study.

Abstract Background Reverse total shoulder arthroplasty (RTSA) has emerged as a successful surgery with expanding indications. Outcomes may be influenced by post-operative rehabilitation; however, there is a dearth of research regarding optimal rehabilitation strategy following RTSA. The primary purpose of this study is to compare patient reported and clinical outcomes after RTSA in two groups: in one group rehabilitation is directed by formal, outpatient clinic-based physical therapists (PT group) as compared to a home therapy group, in which patients are instructed in their rehabilitative exercises by surgeons at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care and quality of life between the two groups. Methods This randomised controlled trial has commenced at seven sites across the United States. Data is being collected on 200 subjects by clinical research assistants pre-operatively and post-operatively at 2, 6, and 12 weeks, 6 months, 1 and 2 year visits. The following variables are being assessed: American Shoulder and Elbow Surgeons (ASES), pain level using the numeric pain scale, the Single Assessment Numeric Evaluation (SANE) score, and shoulder active and passive range of motion for analysis of the primary aim. Chi square and t-tests will be used to measure differences in baseline characteristics of both groups. Repeated measures linear mixed effects modeling for measurement of differences will be used for outcomes associated with ASES and SANE and scores, and range of motion measures. Secondary aims will be analyzed for comparison of complications, cost, and quality of life assessment scores using data obtained from the PROMIS 29 v. 2, questionnaires administered at standard of care post-operative visits, and the electronic health record. Subjects will be allowed to crossover between the PT and HT groups, and analysis will include both intention-to-treat including patients who crossed over, and a second with cross-over patients removed, truncated to the time they crossed over. Discussion RTSA is being performed with increasing frequency, and the optimal rehabilitation strategy is unclear. This study will help clarify the role of formal physical therapy with particular consideration to outcomes, cost, and complications. In addition, this study will evaluate a proposed rehabilitation strategy. Trial registration This study is registered as NCT03719859 at ClincialTrials.gov.

Background: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability. Methods: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. Results: Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice similar to 10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure. Conclusion: The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: With the continued rise in health care costs, value-based care in orthopedics is more important than ever. Health care providers, policymakers, and insurance companies all have input into defining and setting the level of this value. The purpose of this study was to evaluate patient perception of value in rotator cuff repair (RCR) and total shoulder replacement (TSA) using a population composed only of patients who underwent the procedure. Methods: We were able to obtain complete data from 191 of the 250 patients in the RCR cohort and 211 of the 250 patients in the TSA cohort. Patients were asked what they believe a surgeon should be reimbursed for performing RCR or TSA, what they would be willing to pay for the procedure, and to rate the importance of each aspect of their care. Patients then estimated what Medicare reimbursed for the procedure they underwent. Results: The mean result for patients surveyed regarding a reasonable fee for surgeons was $9870 for RCR and $14,231 for TSA. The mean patient estimate for actual Medicare reimbursement was $5705 for RCR and $9372 for TSA. Fifty-seven percent thought that payment for RCR was too low, and 76% thought that it was too low for TSA. When asked to rate the importance of each aspect of their care, RCR patients felt that 46% should go to the surgeon. TSA patients felt that surgeons should receive 47%. Conclusion: In agreement with prior studies, patients perceived the monetary value of RCR and TSA to be much higher than current Medicare schedules. Conclusion: In agreement with prior studies, patients perceived the monetary value of RCR and TSA to be much higher than current Medicare schedules. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: This study assessed the current political standings and active political engagement of American Shoulder and Elbow Surgeons (ASES) members along with the political process as it relates to health care policy. Methods: This survey study involved 552 ASES members. The survey was open for 2 weeks. Responses were received from 254 of the 552 members (46%), and their answers were analyzed. Results: Six (2%) of the responding members were solo practitioners, 100 (39%) belonged to a private practice, 106 (42%) were providers at academic institutions or residency training programs, 25 (10%) were employed by a hospital, and 17 (7%) categorized themselves as other. Email was the preferred method of communication. Of all responding members, 110 (43%) stated they had contributed to the American Academy of Orthopaedic Surgery Political Advocacy Committee in the last 12 months. Four (10%) of the responding members have a relationship with an elected official, and 220 (87%) would be willing to become a key contact and reach out to a legislator. Conclusion: Moving forward, this survey can be used to better shape the political advocacy efforts of the ASES and potentially other subspecialty societies. The response that "a high percentage of members would like to be more involved" suggests the need for a program to help further educate and facilitate the membership on political advocacy. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Fractures of the clavicle are common injuries that occur across all age groups but are most frequently seen in the young, active patient population. Among the different types of clavicle fractures, those occurring in the middle third of the clavicular shaft are the most common. Historically, most of these fractures were treated by closed means even when notable displacement was present. Recently, there has been a renewed interest in assessing the best treatment option for these patients. Although nonsurgical treatment is a reliable method for treating many of these fractures, more recent data suggest that fractures with notable displacement (>2 cm of shortening or >100% displacement) and/or comminution have better short-term outcomes and lower rates of nonunion with surgical management. Current surgical options include superior plating, anterior-inferior plating, dual plating, and intramedullary nail fixation.

Although most proximal humerus fractures can be treated nonoperatively, 4-part fractures and 3-part fractures/dislocations in elderly patients often require management with prosthetic arthroplasty. Reverse arthroplasty is gaining in popularity, but hemiarthroplasty still has a role in the management of 4-part and some 3-part fractures and dislocations. The 2 most important technical factors influencing functional outcome in hemiarthroplasty patients are the restoration of the patient's correct humeral head height and version, and healing of the greater and lesser tuberosities in an anatomic position. Hemiarthroplasty for proximal humerus fracture provides predictable pain relief, but functional recovery is much less predictable.

Background: A previous study revealed that patients perceived physician reimbursement to be much higher than current Medicare schedules for hip and knee replacement. The purpose of this study was to evaluate patient perception of surgeon reimbursement for total shoulder replacement (TSA) and rotator cuff repair (RCR).Methods: The study surveyed 250 patients. Patients were asked what they believe a surgeon should be reimbursed for performing TSA and RCR. Patients were then asked to estimate what Medicare reimbursed for each of these procedures. We then revealed the Medicare reimbursement rate for TSA and RCR, and patients were asked to comment. Finally, patients were asked whether surgeons with advanced shoulder training should receive additional payments.Results: Patients thought that surgeons should receive $13,178 for TSA and $8459 for RCR. Patients estimated actual Medicare reimbursement was $7177 for TSA and $4692 for RCR. Eighty percent of patients stated that Medicare reimbursement was too low for TSA, 75% thought that payment for RCR was lower than what it should be. Less than 1% of patients felt that it was higher than it should be. A total of 87% of patients thought that surgeons with advanced shoulder training should be reimbursed at a higher rate.Conclusion: Patients perceived the values of TSA and RCR were much higher than current Medicare schedules. This is in agreement with prior surveys. Continued decreases in Medicare reimbursements may force surgeons to not participate in Medicare and create a potential access issue. Further investigation should focus on identifying how many surgeons may opt out. (C) 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.

Deep venous thrombosis and pulmonary embolism events are common complications following lower-extremity orthopedic surgery. Conversely, deep venous thrombosis and pulmonary embolism events are rare following upper-extremity surgery, specifically shoulder arthroscopy. The purpose of this article is to emphasize the necessity of performing a thorough preoperative workup to uncover possible risk factors for deep venous thrombosis/pulmonary embolism despite the rare occurrence of developing a pulmonary embolism following shoulder arthroscopy. This article describes 3 patients who developed a nonfatal pulmonary embolism following elective shoulder arthroscopy. All 3 surgeries were performed with the patient in the lateral decubitus position. No complications were noted intraoperatively. Symptoms appeared at postoperative days 14, 29, and 2, respectively. One patient demonstrated no risk factors for developing a pulmonary embolism, whereas the other 2 exhibited risk factors for deep venous thrombosis and pulmonary embolism. Pulmonary embolism is a rare but serious complication following shoulder arthroscopy. Shoulder surgeons should be aware of the presenting signs and symptoms. Mechanical or chemical prophylaxis should be administered for patients with identified coagulopathic risk factors. Although it is rare for patients to develop a pulmonary embolism following upper-extremity shoulder arthroscopy, orthopedic surgeons must be aware of the possibility that a pulmonary embolism can occur after elective, uncomplicated shoulder arthroscopy. Surgeons should consider prophylactic measures for patients with identified coagulopathy disorders.

Introduction: The range of motion (ROM) in the wrist and elbow required for daily activities has been reported to be less than the normal anatomic ROM. This functional ROM has not been defined for the shoulder. Many shoulder outcome assessment tools use specific functional tasks of daily living to score functional results of treatment. This study quantified the total shoulder ROM required to perform the functional tasks of the American Shoulder and Elbow Surgeon (ASES), Simple Shoulder Test (SST), and University of Pennsylvania (U-Penn) Shoulder Score (PSS).Materials and methods: The FASTRAK electromagnetic tracking system (Colchester, VT, USA) was used to test 40 shoulders in 20 volunteers with no shoulder pathology found on physical examination. Three sensors were used: 1 each on the T3 spinous process, the scapular spine, and the arm over the distal humerus. Subjects performed each functional task of the ASES, SST, and PSS while flexion, extension, abduction, adduction, external rotation, and internal rotation were recorded.Results: Average shoulder motions required to perform the 10 functional tasks were flexion, 121 degrees +/- 6.7 degrees; extension, 46 degrees +/- 5.3 degrees; abduction, 128 degrees +/- 7.9 degrees; cross-body adduction, 116 degrees +/- 9.1 degrees; external rotation with the arm 90 degrees abducted, 59 degrees +/- 10 degrees; and internal rotation with the arm at the side, 102 degrees +/- 7.7 degrees.Conclusion: Although attaining full motion is a reasonable goal of all shoulder treatment, our results indicate that less ROM is required to perform the functional tasks used in common outcome tools.Level of evidence: Basic Science Study, Kinesiology Study. (C) 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

BACKGROUND:Very little data exist on latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers.PURPOSE:This review was undertaken to report on the management and outcomes of baseball pitchers with injury to 1 or both of these muscles.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:A retrospective review of 16 professional baseball pitchers diagnosed and treated for an LD and/or TM tear between 2002 and 2008 was performed. Magnetic resonance imaging confirmed the diagnosis in all cases. The mean age was 28.1 years. All were treated nonoperatively with rest, rehabilitation, and return to pitching after a throwing program. The injuries included tendon avulsions in 6 athletes and strains in 10. Length of disabled time, return to prior level of pitching, and recurrences were noted.RESULTS:Fifteen of 16 pitchers (94%) returned to the same or higher level of play. The mean time to throwing was 35.6 days. Mean time to pitching was 61.9 days. Nine of 16 injuries (56%) were season-ending. Mean total time lost for athletes returning the same season was 82.4 days. Two of 16 pitchers (13%) sustained recurrent injuries. Prior shoulder and elbow injuries were noted in 75% (12 of 16).CONCLUSION:Injury of the LD and/or TM can occur in pitchers. Nonoperative treatment is successful in allowing a return to high-level pitching.

Luxatio erecta humeri is a rare clinical entity, comprising 0.5% of all glenohumeral dislocations.(1) Even more uncommon, open luxatio erecta has only been described three times dating back to the 1800s.(2-4) These cases report poor results including death from sepsis, avascular necrosis, and severely limited motion. We now report a fourth case of open luxatio erecta secondary to a work-related injury.

BACKGROUND:Prior studies suggest the cost of allograft anterior cruciate ligament (ACL) reconstruction is less than that for autograft reconstruction. Charges in these studies were influenced by patients requiring inpatient hospitalization. QUESTION/PURPOSE: We therefore determined if allograft ACL reconstruction would still be less costly if all procedures were performed in a completely outpatient setting.METHODS:We retrospectively reviewed 155 patients who underwent ACL reconstruction in an ambulatory surgery center between 2001 and 2004; 105 had an autograft and 50 had an allograft. Charges were extracted from itemized billing records, standardized to eliminate cost increases, and categorized for comparison. Surgeon and anesthesiologist fees were not included in the analysis. Groups were compared for age, gender, mean total cost, mean cost of implants, and several other cost categories.RESULTS:The mean total cost was $5465 for allograft ACL reconstruction and $4872 for autograft ACL reconstruction. There were no differences in complications between the two groups.CONCLUSIONS:Allograft ACL reconstruction was more costly than autograft ACL reconstruction in the outpatient setting. The cost of the allograft outweighs the increased surgical time needed for harvesting an autograft.LEVEL OF EVIDENCE:Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.