Bartels, D

Background: Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty. Methods: From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Results: Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI. Conclusions: In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Glenoid component loosening is a primary cause of failure of anatomical total shoulder arthroplasty (TSA) and is commonly associated with glenoid bone loss. The purpose of the present study was to evaluate the outcome and survival following revision to a reverse total shoulder arthroplasty (RSA) for the treatment of loosening of a polyethylene cemented glenoid component in the setting of failed TSA. Methods: Between 2010 and 2017, 151 shoulders underwent revision to RSA for the treatment of loosening of an anatomical polyethylene glenoid component. Shoulders with staged reconstruction for the treatment of infection were excluded. One hundred and twenty-seven patients (67 women and 60 men) had a single-stage reconstruction and were available for follow-up. The mean age at the time of surgery was 70 years (range, 41 to 93 years). In all cases, the humeral component was revised and a standard glenoid baseplate was utilized. Bone graft was used at the discretion of the treating surgeon. Medical records and radiographs were reviewed to collect demographic, intraoperative, and postoperative data; to quantify glenoid bone loss; and to determine the radiographic outcome. The mean duration of follow-up was 35 months (range, 24 to 84 months). Results: Revision to RSA resulted in significant improvements in terms of pain and motion. Sixteen shoulders (13%) underwent revision surgery for the treatment of baseplate loosening. Radiographic baseplate loosening was present in 6 additional shoulders (overall rate of baseplate loosening, 17%). Intraoperative fracture or fragmentation of the greater tuberosity occurred in 30 shoulders (24%). Other reoperations included resection for deep infection (3 shoulders), arthroscopic biopsies for unexplained persistent pain (2 shoulders), humeral tray exchange for dislocation (2 shoulders), revision for humeral loosening (1 shoulder), irrigation and debridement for hematoma (1 shoulder), and internal fixation of periprosthetic fracture (1 shoulder) (overall reoperation rate, 20%). Among shoulders with surviving implants at the time of the most recent follow-up, pain was rated as none or mild in 83 shoulders (65.4%) and the average active elevation and external rotation were 132° and 38°, respectively. With the numbers available, no risk factors for failure could be identified. Conclusions: Revision RSA for the treatment of loosening of an anatomical polyethylene component was associated with a 17% glenoid mechanical failure rate. Although this procedure resulted in improvements in terms of pain and function, it was not universally successful and thus needs further refinement in order to improve outcomes. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Case: A 51-year-old man presented with pain and paresthesias in the median nerve distribution and a subjective loss of grip strength. Imaging revealed a thrombosed persistent median artery in the carpal tunnel abutting the median nerve. The thrombosed portion of the artery was surgically excised, and the patient experienced resolution of symptoms. Conclusion: Persistent median artery thrombosis is rare and can cause carpal tunnel syndrome. Ultrasound is a useful tool for diagnosis and appropriate surgical planning. Although treatment with systemic anticoagulation is an option, surgical excision resulted in resolution of symptoms and an excellent short-term outcome.

Objectives: Participation in National Collegiate Athletic Association (NCAA) football is at an all-time high. This population experiences a substantial injury burden with many of these injuries affecting the upper extremities. The NCAA has adopted a data-driven decision-making process when providing recommendations for protecting player safety. The purpose of this study was to describe the epidemiology of hand and wrist injury in NCAA football in an effort to provide meaningful data for tailoring effective injury prevention strategies. Methods: An epidemiologic study utilizing the NCAA Injury Surveillance Program (NCAA-ISP) database was performed to investigate rates and patterns of hand and wrist injury in NCAA varsity football teams participating in the NCAA-ISP from 2009 to 2014. Descriptive statistics were used to present demographic data. Injury rates were calculated per 1000 athlete-exposures (AEs) using statistical cross-referencing between injury-level and event-level data. Injury mechanism and severity, as measured by time-loss from play, were determined and compared between exposure factors such as player position, player seniority, and practice versus game setting. Results: 725 hand and wrist injuries were captured in 899,225 AEs. The observed practice hand and wrist injury rate was 0.51 injuries per thousand AEs, which was significantly lower than the game injury rate of 3.60 (p < 0.01). Comparing player demographics for injuries sustained during practice as opposed to game time revealed significant differences based on player year, player position, activity performed at the time of injury, and mechanism of injury (p < 0.01, Figure 1). Player-on-player contact was the most common injury mechanism reported with blocking being the most common activity at injury. Of all sustained injuries, 71.4% resulted in no time loss from competition whereas 9.8% of injuries resulted in greater than 7 days of time loss. On average, fracture resulted in the greatest time loss from competition (8.3 ± 24.0 days for injuries sustained in practice setting, 7.7 ±15.8 days for injuries sustained in game setting). When comparing injury by location, hand injury resulted in greater time loss (3.7 ± 15.1, 4.4 ± 13.8) than to nail/subungual (0±0, 0±0), finger (1.6 ± 6.7, 1.1 ± 4.2), and wrist injury (1.2 ± 3.8, 1.8 ± 4.9). Conclusion: This study characterizes the incidence of NCAA football hand and wrist injuries in both practice and game settings and demonstrates the relatively low rate of injuries leading to loss of playing time. Hand and wrist injury was found to be significantly more common in games when compared to practice. Offensive linemen were the most commonly affected players in the cohort, with most injuries occurring during game time compared to practice. This study provides valuable prognostic data regarding expected time loss from play on a per injury pattern basis. Further investigation on specific injury subtypes and expected time loss as a result of these injures would provide trainers, players, and coaches with useful information on an expected post-injury recovery and rehabilitation timeline. [Figure: see text]

Aims Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA). Patients and Methods A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m2 (17.3 to 66.4). Results Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred. Conclusion Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610–614.

Background: Participation in National Collegiate Athletic Association (NCAA) football is at an all-time high. This population of athletes experiences a substantial injury burden, with many injuries affecting the upper extremities. Purpose/Hypothesis: The purpose of this study was to describe the epidemiology of hand and wrist injuries in college football players from the academic years 2009–2010 to 2013–2014. We hypothesized that variables such as event type (practice vs game), mechanism of injury, and player position would have an effect on the injury incidence. Study Design: Descriptive epidemiological study. Methods: An epidemiological study utilizing the NCAA Injury Surveillance Program was performed to investigate rates and patterns of hand and wrist injuries in participating varsity football teams from 2009–2010 to 2013–2014. Results: A total of 725 hand and wrist injuries were captured in 899,225 athlete-exposures. The observed practice injury rate was 0.51 injuries per 1000 athlete-exposures, compared with a game injury rate of 3.60 ( P < .01). Player-on-player contact was the most common injury mechanism reported, with blocking being the most common activity at the time of injury. Offensive linemen were most likely to experience an injury. Of all injuries sustained, 71.4% resulted in no time loss from competition, whereas 9.8% of injuries resulted in longer than 7 days of time loss. A fracture resulted in the greatest time loss from competition (mean ± SD, 8.3 ± 24.0 days; median, 0 days [range, 0-148 days] for injuries sustained in a practice setting) (mean ± SD, 7.7 ± 15.8 days; median, 0 days [range, 0-87 days] for injuries sustained in a game setting). Conclusion: Hand and wrist injuries were found to be significantly more common in games when compared with practices. This study provides valuable prognostic data regarding expected time loss on a per-injury pattern basis. Further investigation on specific injury subtypes and expected time loss as a result of these injures would provide trainers, players, and coaches with useful information on an expected postinjury recovery and rehabilitation timeline.