Tej Joshi

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.

Background: Advantages of preoperative planning computed tomography (CT) scans for shoulder arthroplasty (SA) are known; however, risks of ionizing radiation exposure remain unknown. We retrospectively reviewed institutional trends in utilization and estimated radiation risk of preoperative planning CT scans obtained for SA. Methods: From 2016 to 2024, the annual percent incidence of SA patients that received a preoperative planning CT was determined. The National Academy of Sciences Biological Effects of Ionizing Radiation VII report on lifetime attributable risk (LAR) cancer incidences and received radiation dose were utilized to estimate patient-level LAR projections for 100 patients stratified by sex, age, and cancer type. Results: From 2016 to 2024, utilization of preoperative planning CT increased linearly (R ² = 0.78) from 53% to 66% of all SA patients. For all solid cancers, LAR (per 100,000 people) decreased as patient age increased, ranging from 73.1 to 9.6 for females and 40.7 to 31.4 for males (from the 50–59-year-old group to the 80–89 group). In the 60–69-year-old and 70–79-year-old groups, estimated thyroid and lung LARs were significantly higher in women. Discussion: Utilization of preoperative shoulder CT scans is increasing. Preoperative shoulder CT may be associated with a small but quantifiable projected cancer risk most pronounced in younger women.

» Isolated greater tuberosity (GT) fractures account for approximately 20% of all proximal humerus fractures. » Displaced GT fractures can compromise the rotator cuff biomechanics and behave as rotator cuff deficient shoulders, leading to weakness (external rotation and scaption strength), loss of range of motion (elevation, abduction, external rotation), and subacromial impingement. » Most nondisplaced to minimally displaced fractures (<5 mm) can be treated nonsurgically with good outcomes. Secondary displacement of GT fractures is low, but the presence of associated shoulder instability predisposes patients to a higher risk, and thus, these patients should be monitored closely. » Displaced fractures benefit from surgical treatment. A tension band construct or buttressing mechanism is required to neutralize the deforming force of the posterior and superior rotator cuff on fracture fixation. » There is no consensus on the surgical approach (arthroscopic vs. open) and type of fixation (plate, screws alone, suture anchor repair, or hybrid fixation) for the surgical treatment of these fractures. Each fixation option has its own unique profile of advantages and risks, emphasizing the importance of individualized management. » Small (<1 cm) avulsion or depressed type fractures are amenable to arthroscopic treatment with suture anchor repair, with or without screw fixation, resulting in good outcomes. » Open repair is more common in split type fracture patterns or fractures with a large fracture fragment. There is no consensus on the surgical approach (deltopectoral vs. anterolateral or lateral deltoid approach) for open repair.

Background Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially life-threatening complication following total shoulder arthroplasty (TSA). Despite the increased use of chemical prophylaxis, its effectiveness and safety in TSA populations remain unclear. This study evaluated the incidence of VTE, bleeding events, and related outcomes among TSA patients with and without postoperative chemical prophylaxis. Materials and methods A retrospective cohort study was conducted using the TriNetX database, identifying patients who underwent TSA, stratifying into two cohorts: those who received chemical VTE prophylaxis and those who did not. Propensity score matching (1:1) was employed to balance demographics, comorbidities, and other confounding variables. Outcomes, including VTE, bleeding events, prosthetic joint infection (PJI), revision, and mortality, were assessed at 30 days, 90 days, and 6 months postoperatively. Results After matching, 9,859 patients were included in each cohort. There was no significant difference in the incidence of VTE, PE, or DVT at any time point between the groups. Patients who received prophylaxis showed a reduced risk of ischemic stroke at 30 days (HR 0.539; 95% CI 0.367–0.793; p = 0.001) and myocardial infarction (MI) at both 30 days (HR 0.469; 95% CI 0.306–0.718; p < 0.001) and 90 days (HR 0.720; 95% CI 0.519–0.997; p = 0.047). However, at 6 months, patients with prophylaxis demonstrated an increased risk of mortality (HR 1.812; 95% CI 1.003–3.273; p = 0.046). Conclusion Chemical prophylaxis did not reduce the risk of VTE after TSA but was associated with a lower incidence of ischemic stroke and MI in the early postoperative period. The increased long-term mortality risk observed in the prophylaxis group warrants further investigation to optimize VTE prevention strategies for TSA patients. Level of evidence Level III Retrospective Cohort Comparison Using Large Database Prognosis Study.

» 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.

Background: Total shoulder arthroplasty (TSA) is an effective treatment for advanced osteonecrosis (ON) of the humeral head, a condition involving vascular disruption and bone necrosis. However, systemic comorbidities in ON patients may impact postoperative outcomes. Purposes: We sought to evaluate health care utilization, systemic complications, and implant-related outcomes in TSA patients with and without ON. Methods: Using the TriNetX research database, we identified patients who underwent TSA between December 9, 2002, and December 9, 2022. Two cohorts were created: The TSA + ON cohort included patients with any ON diagnosis of the humerus within 1 year leading to their TSA, and the TSA-only cohort excluded patients with ON of the humerus within the same timeframe. Propensity score matching was used to balance comorbidities. Outcomes—including emergency department (ED) visits, readmissions, adverse events, and prosthetic complications—were assessed at 30th day, 90th day, and 1st year. The Benjamini-Hochberg method was applied to control the false discovery rate. Results: The query identified 1281 patients with ON and 71 201 patients without ON who underwent primary TSA. After matching, each group consisted of 1218 patients. There were no significant differences in ED visits or readmissions between cohorts after correction. Systemic complications were similar, except for acute kidney injury at the 90th day, which was more frequent in the TSA + ON group. No other adverse events reached significance. Implant-related outcomes, including prosthetic joint infection and revision, were comparable. Conclusion: The findings of this retrospective cohort database study suggest that TSA may be safe and effective in ON patients, with similar implant outcomes to non-ON patients. However, the increased rate of acute kidney injury we found at the 90thday in the TSA + ON cohort suggests the need for closer perioperative renal monitoring and supports individualized risk stratification to improve outcomes in this population. Level of Evidence: Level III: retrospective cohort database study.