Faculty Bibliography

Primary elbow osteoarthritis is a functionally limiting condition, predominantly affecting middle-aged men engaged in repetitive manual labor, and is characterized by pain, stiffness, and mechanical symptoms. Evaluation involves a detailed history focusing on pain, loss of motion, and mechanical symptoms, followed by clinical examination for range of motion deficits, crepitus, and instability. Radiographic assessment, including standard radiographs and, when indicated, computed tomography imaging, is essential for staging disease severity, identifying osteophytes, capsular contracture, and joint space narrowing. Initial management is nonsurgical, emphasizing activity modification, NSAIDs, physical therapy, and intra-articular corticosteroid injections. When conservative measures fail, surgical options include arthroscopic or open débridement, osteocapsular arthroplasty, and procedures such as the Outerbridge-Kashiwagi technique. Both arthroscopic and open approaches reliably improve pain, range of motion, and functional scores, with low complication rates. However, open procedures may yield greater flexion gains in select cases. Nonarthroplasty options for primary elbow arthritis encompass a spectrum from conservative management to arthroscopic and open surgical débridement, with treatment tailored to disease severity, patient age, and functional demands.

» Distal clavicle fractures are less common, accounting for 10% to 30% of all clavicle fractures. » The presence of radiographic nonunion does not correlate with symptomatic nonunion, with a variable percentage of patients necessitating subsequent surgical intervention (20%). » Fracture displacement is associated with a higher risk of nonunion (31%-37%), particularly in Neer type II and V fracture patterns. » Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). » Surgical treatment is indicated for displaced Neer type II and V fractures. Increased radiographic coracoclavicular (CC) distance in type II and V fractures is an indication for CC stabilization. However, there is no consensus on ideal fixation techniques for fracture fixation and CC stabilization. » Surgical treatment may require secondary implant removal, regardless of the fixation construct used (28%-55%) but especially common with hook plate fixation.

INTRODUCTION/BACKGROUND:Prosthetic joint infection is a serious complication after primary shoulder arthroplasty, yet no standardized infection prevention protocol exists. This study evaluated current trends in infection prevention among members of the American Shoulder and Elbow Surgeons. METHODS:A 25-item cross-sectional survey was developed to capture commonly used preoperative, intraoperative, and postoperative infection prevention strategies in primary shoulder arthroplasty. The finalized instrument was administered electronically through REDCap to all active American Shoulder and Elbow Surgeons members in November 2024, with 1 reminder sent 2 weeks later. Anonymized responses were categorized by years in practice (<5, 5-10, 10-20, and >20 years). Statistical analyses assessed variability across experience groups. RESULTS:Of 229 responses, 224 were complete and included for analysis. Most surgeons reported using hemoglobin A1c cutoffs (77%), avoiding corticosteroid injections within 3 months of surgery (86%), performing preoperative skin cleansing (78%), using chlorhexidine for preparation (94%), switching scalpel blades (80%) or using electrocautery (79%) after skin incision, and administering perioperative IV antibiotics (76%). Surgeons with <5 years of experience were more likely to use hydrogen peroxide or alcohol-based skin preparation, vancomycin powder, topical skin glue, silver-impregnated dressings, and apply stricter hemoglobin A1c cutoffs, reaching statistical significance in all cases (P < .05). A body mass index cutoff was used by 25% of respondents, with a mean threshold of 42 kg/m2. CONCLUSION/CONCLUSIONS:Substantial variation exists in infection prevention strategies for primary shoulder arthroplasty (SA) across experience levels, highlighting the need for standardized protocols. LEVEL OF EVIDENCE/METHODS:IV, epidemiological study.

» Based on the available evidence, there are numerous strategies that may reduce infection risk in primary shoulder arthroplasty. Preoperatively, optimization of iron deficiency anemia and smoking cessation are associated with lower rates of periprosthetic joint infection and perioperative complications. In addition, risk of infection may be mitigated by deferring shoulder arthroplasty for at least three months following a corticosteroid injection. Management of biologic and targeted immunosuppressive therapies should be coordinated with medical specialists and tailored to the specific agent's pharmacokinetics and surgical risk.» Preoperative skin preparation with agents such as benzoyl peroxide or chlorhexidine gluconate may decrease bacterial colonization. Antibiotic prophylaxis with a single preoperative dose of cefazolin administered within one hour of incision reduces infection risk, and in patients with true beta-lactam allergy, fully infused vancomycin prior to incision is an effective alternative. Intraoperatively, measures such as dilute betadine lavage, vancomycin powder, chlorhexidine wash, and antibiotic irrigation can reduce bacterial contamination. Additional intraoperative techniques including electrocautery after skin incision may further decrease bacterial burden, although higher level evidence for these latter interventions remains limited or conflicting.

BACKGROUND:The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA). METHODS:All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery). RESULTS:Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively. CONCLUSION/CONCLUSIONS:Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [Orthopedics. 2023;46(3):e161-e166.].

BACKGROUND:Arthroscopic debridement is an effective means of surgical management of both degenerative osteoarthritis (DOA) and posttraumatic arthritis (PTA) of the elbow. However, the difference in the efficacy and longevity of this procedure when performed for these two distinct pathologies remains in question. The purpose of this study was to identify and compare the midterm outcomes and survivorship of arthroscopic debridement of elbow PTA and DOA. METHODS:A retrospective analysis of patients undergoing arthroscopic debridement of DOA and PTA of the elbow was performed. A questionnaire containing the Oxford Elbow Score, as well as questions regarding the incidence of reoperation, additional nonoperative intervention, complications, pain, and satisfaction, was given at 5 years, minimum, after surgery. The midterm survivorship of arthroscopic debridement free of reoperation for any reason, as well as the remaining outcome measurements obtained via the questionnaire and in-office evaluation, was compared between PTA and DOA cohorts. RESULTS: < .001) and ROM. Postoperative ROM was obtained at the final clinic visit at an average follow-up duration of 151 days and 255 days in the DOA and PTA cohorts, respectively. However, no difference in the degree of improvement in either outcome variable was identified after a comparison between cohorts. CONCLUSION/CONCLUSIONS:Arthroscopic debridement is an equally efficacious treatment option for DOA and PTA of the elbow. Patients with either pathology can expect satisfactory elbow function and an improvement in pain with little chance of reoperation at the midterm of the follow-up duration.

BACKGROUND:Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. METHODS:Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. RESULTS:Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. CONCLUSION/CONCLUSIONS:The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

BACKGROUND/UNASSIGNED:Numerous attempts have been made to decrease the incidence of opioid dependence after orthopedic surgeries. However, no effective means of preoperative risk stratification currently exists. The purpose of this study was to determine the ability of the Opioid Risk Tool (ORT) to predict the rate of opioid dependence 2 years after arthroscopic rotator cuff repair (ARCR). METHODS/UNASSIGNED:We prospectively evaluated all patients undergoing primary ARCR at a single institution over a 1.5 year period with a minimum of 2-year follow-up. All patients completed the ORT prior to surgery and were stratified into Low, Moderate, and High risk categories. The primary outcome was postoperative opioid dependence, defined as receiving a minimum of 6 opioid prescriptions within 2 years following surgery. Secondary outcomes included the total number of morphine milligram equivalents prescribed, total number of opioid prescriptions filled, and total number of opioid pills prescribed during this time interval. All outcome variables were compared amongst Low, Moderate, and High risk groups. Assessment of a statistical correlation between each outcome variable and individual numerical ORT scores (1-9) was performed. RESULTS/UNASSIGNED:A total of 137 patients were included for analysis. No statistically significant difference was noted in any primary or secondary outcome variable when compared between Low, Moderate, and High risk groups. The total cohort demonstrated a 19% rate of post-operative opioid dependence. No correlation was identified between any outcome variable and individual numerical ORT scores. A greater rate of dependence and quantity of opioids prescribed was noted amongst patients with a history of prior opioid use. CONCLUSION/UNASSIGNED:The ORT was not predictive of the risk of opioid dependence or quantity of opioids prescribed after ARCR. Attention should be focused on alternative means of identification and management of patients at risk for opioid dependence after orthopedic procedures, including those with a history of prior opioid use.

PURPOSE:We sought to determine the effectiveness of corticosteroid injections (CSIs) for de Quervain tenosynovitis in patients with diabetes mellitus. METHODS:We retrospectively identified all patients with diabetes receiving a CSI for de Quervain tenosynovitis by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, number and timing of CSIs, and first dorsal compartment release. Success was defined as not undergoing an additional CSI or surgical intervention. The mixture of a corticosteroid and local anesthetic provided in each injection was at the discretion of each individual surgeon. RESULTS:Corticosteroid injections were given to 169 wrists in 169 patients with diabetes. Out of 169 patients, 83 (49%) had success following the initial CSI, 44 (66%) following a second CSI, and 6 (67%) following a third CSI. A statistically significant difference was identified in the success rates between the first and second CSIs. Ultimately, 36 of 169 wrists (21%) underwent a first dorsal compartment release. CONCLUSIONS:Patients with diabetes mellitus have a decreased probability of success following a single CSI for de Quervain tenosynovitis in comparison to nondiabetic patients, as described in the literature. However, the effectiveness of each additional CSI does not appear to diminish. TYPE OF STUDY/LEVEL OF EVIDENCE:Therapeutic IV.