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BACKGROUND: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored. PURPOSE: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed. RESULTS: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios. CONCLUSION: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage. REGISTRATION: NCT01324531 (ClinicalTrials.gov identifier).

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BACKGROUND: The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used. METHODS: Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA + EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. RESULTS: One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA + EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P < .001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P < .001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups. CONCLUSION: Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used.

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BACKGROUND: First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes. METHODS: We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies. RESULTS: We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided. CONCLUSION: This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.

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AIM: The suicide rate among college students is particularly high, with evidence that psychosis-like experiences (PLEs) put these individuals at greater risk. The current study explored whether there are differential relations between four subtypes of PLEs and three suicide outcomes. METHODS: We analysed a large sample of college students from the Fall semester cohort of the 2020 Healthy Minds Study (HMS) (weighted N = 36727). PLEs and suicide outcomes were assessed using binary variables from the World Health Organization Composite International Diagnostic Interview. RESULTS: Findings revealed that reporting any of the subtypes of PLEs was associated with greater odds of suicidal ideation (SI), a suicide plan (SP) and a suicide attempt (SA) (signficant a ORs ranging from 1.30 to 3.30). For college students who endorsed SI or a SP in the past year, experiencing delusional mood (aOR [95% CI] = 1.30 [1.02-1.65]), suspiciousness (aOR [95% CI] = 1.31 [1.00-1.71]) and hallucinatory experiences (aOR [95% CI] = 2.76 [2.05-3.71]) in their lifetime increased their odds of reporting a SA in the past year. There was also evidence of a dose-dependent relation between the number of PLEs endorsed and all three suicide outcomes. CONCLUSIONS: Certain subtypes of PLEs including delusional mood, suspiciousness and hallucinatory experiences may contribute to an elevated risk of suicide outcomes in college students. Moreover, the odds of reporting suicide outcomes were greater for individuals who endorsed a greater number of PLEs. It may be helpful to assess for indicated subtypes when determining suicide risk among college students and to be particularly mindful of those who report three or more PLEs.

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BACKGROUND & HYPOTHESIS: Psychotic disorders are inequitably distributed by race in the United States, although it is not known whether this is due to assessment biases or inequitable distributions of risk factors. Psychotic experiences are subclinical hallucinations and delusions used to study the etiology of psychosis, which are based on self-report and therefore not subject to potential clinician biases. In this study, we test whether the prevalence of psychotic experiences (PE) varies by race and if this variance is explained by socioenvironmental risk factors. STUDY DESIGN: Data on demographics, PE, and socioenvironmental risk factors were collected through the National Survey of Poly-victimization and Mental Health, a national probability sample of US young adults. Logistic regression analyses were used to determine whether PE prevalence varied by race/ethnicity and, if so, whether this was attenuated with inclusion of indicators of income, education, urban/rural living, discrimination, and trauma exposure. STUDY RESULTS: Black and Hispanic respondents reported PE at significantly greater rates than White or "other" ethnoracial groups, with hallucinations more commonly reported by Hispanic respondents. PE were significantly associated with police violence exposure, discrimination, adverse childhood experiences, and educational attainment. These factors statistically explained ethnoracial differences in the likelihood of overall PE occurrence and of nearly all PE subtypes. CONCLUSIONS: Previously observed racial differences in psychosis extend beyond clinical schizophrenia, and therefore, are unlikely to be explained entirely by clinician biases. Instead, racial disparities in PE appear to be driven by features of structural racism, trauma, and discrimination.

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BACKGROUND: Despite recent advances in arthroscopic rotator cuff repair, the retear rate remains high. New methods to optimize healing rates must be sought. Bone channeling may create a quicker and more vigorous healing response by attracting autologous mesenchymal stem cells, cytokines, and growth factors to the repair site. HYPOTHESIS: Arthroscopic rotator cuff repair with bone channeling would result in a higher healing rate compared with arthroscopic rotator cuff repair without adjuvant channeling. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Secondary objectives included comparisons of the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Constant strength subscore, and visual analog scale (VAS) for pain score between groups. Patients undergoing arthroscopic rotator cuff repair were recruited at 3 sites and were randomized to receive either bone channeling augmentation or standard repair. Healing was determined via ultrasound at 24 months postoperatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12, and 24 months postoperatively. RESULTS: A total of 168 patients were enrolled between 2013 and 2018. Intention-to-treat analysis revealed no statistical differences in healing rates between the 2 interventions at 24 months postoperatively. Statistically significant improvements occurred in both groups from preoperatively to all time points for the WORC, the ASES score, the Constant score or Constant strength subscore, and the VAS for pain (P < .0001). No differences were observed between the bone channeling and control groups in WORC, ASES, Constant, and VAS pain scores at any time point. CONCLUSION: This trial did not demonstrate the superiority of intraoperative bone channeling in rotator cuff repair over standard rotator cuff repair at 24 months postoperatively. Healing rates, patient-reported function, and quality-of-life outcomes were similar between groups. REGISTRATION: NCT01877772 (ClinicalTrials.gov identifier).

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We sought to compare methods of nonsurgical treatment of lateral epicondylitis in men and women older than 18 years to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane through to Mar. 9, 2021, and included all English-language studies comparing nonsurgical approaches. We compared physiotherapy versus no active treatment, corticosteroids versus placebo, platelet-rich plasma (PRP) versus placebo, and autologous blood injection versus placebo. Outcomes of interest were pain outcomes (visual analogue scale scores) and functional outcomes. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking nonsurgical intervention for lateral epicondylitis by improving counselling on nonsurgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various nonsurgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

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BACKGROUND: The COVID-19 pandemic has dramatically altered the way of life in the United States, which may be linked to self-injurious behaviors. METHODS: We conducted a secondary analysis of data from the Fall 2020 Cohort of the Healthy Minds Survey, a non-probability sample of students enrolled at one of 28 universities across the United States. Participants completed an online survey during the COVID-19 pandemic (September-December, 2020). RESULTS: Nearly a quarter of the sample (n = 6999) reported engaging in non-suicidal self-injury (NSSI), 12.41% (n = 3819) reported suicidal ideation, 4.98% (n = 1531) reported making a suicide plan, and 1.09% (n = 334) reported a suicide attempt over the past 12 months. When accounting for all COVID-19 factors in the same model, COVID-19 related concern, COVID-19 related discrimination, financial distress, and infection were significantly associated with NSSI, suicidal ideation, and suicide plan; caregiving was significantly associated with lower odds of engaging in non-suicidal self-injury. None of the factors were associated with suicide attempt. CONCLUSIONS: This study showed that various COVID-19 factors were related to SIB. Interventions may consider multiple dimensions of COVID-19 and their specific impacts.

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BACKGROUND: There is an ongoing controversy regarding the nonoperative treatment of lateral epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral epicondylitis has expanded, an overall assessment of nonoperative treatment options is required. The purpose of this systematic review and meta-analysis was to compare physiotherapy (strengthening), corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or placebo control in patients with lateral epicondylitis. METHODS: MEDLINE, Embase, and Cochrane were searched through till March 8, 2021. Additional studies were identified from reviews. All English-language randomized trials comparing nonoperative treatment of patients >18 years of age with lateral epicondylitis were included. RESULTS: A total of 5 randomized studies compared physiotherapy (strengthening) with no active treatment. There were no significant differences in pain (mean difference: -0.07, 95% confidence interval [CI]: -0.56 to 0.41) or function (standardized mean difference [SMD]: -0.08, 95% CI: -0.46 to 0.30). Seven studies compared CSI with a control. The control group had statistically superior pain (mean difference: 0.70, 95% CI: 0.22 to 1.18) and functional scores (SMD: -0.35, 95% CI: -0.54 to -0.16). Two studies compared PRP with controls, and no differences were found in pain (SD: -0.15, 95% CI: -1.89 to 1.35) or function (SMD: 0.14, 95% CI: -0.45 to 0.73). Three studies compared AB with controls, and no differences were observed in pain (0.49, 95% CI: -2.35 to 3.33) or function (-0.07, 95% CI: -0.64 to 0.50). DISCUSSION: The available evidence does not support the use of nonoperative treatment options including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.

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BACKGROUND: Clinical reports from across the world have documented psychosis in the context of COVID-19 infection; however, there has yet to be a large-scale epidemiological study to confirm this association. METHODS: We analyzed data from the Healthy Minds Study (N = 15,935; conducted between September and December 2020), which was administered online to students attending one of 28 colleges in the United States. Using multivariable logistic regression, we examined the associations between COVID-19 infection/severity and psychotic experiences over the past 12 months, adjusting for age, gender, race/ethnicity, and international student status as well as anxiety and depression. RESULTS: More than one fifth of the analytic sample reported COVID-19 infection, and about one in six students with COVID-19 infection reported psychotic experiences over the past 12 months. In weighted multivariable logistic regression models, COVID-19 infection was associated with significantly greater odds of having psychotic experiences (adjusted odds ratio 1.36, 95% CI 1.19-1.48). Compared with being asymptomatic, having moderate (adjusted odds ratio 1.85, 95% CI 1.03-3.31) or severe (adjusted odds ratio 1.76, 95% CI 1.11-2.77) symptoms was associated with significantly greater odds of having psychotic experiences. These associations became statistically nonsignificant when adjusting for depression and anxiety. Hospitalization was not significantly associated with psychotic experiences among students with COVID-19 infection. CONCLUSIONS: Psychotic experiences are associated with COVID-19 infections, though much of the association is attenuated when accounting for anxiety and depression. Findings based on this sample of college students should be replicated outside of the college context to determine whether psychosis is a neuropsychiatric symptom during and after COVID-19 infection.

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We present 2 cases, 45-year-old identical twin sisters, with bilateral congenital absence of the long head of the biceps tendon (LHBT); 1 twin was symptomatic, while the other was not. Variations of the intra-articular portion of this tendon are widely reported, but there are few reports of cases with absent LHBT. These cases may be of particular interest to radiologists and surgeons because they demonstrate that absent biceps when congenital in nature may not always coincide with symptoms.

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BACKGROUND: Machine learning systems are part of the field of artificial intelligence that automatically learn models from data to make better decisions. Natural language processing (NLP), by using corpora and learning approaches, provides good performance in statistical tasks, such as text classification or sentiment mining. OBJECTIVE: The primary aim of this systematic review was to summarize and characterize, in methodological and technical terms, studies that used machine learning and NLP techniques for mental health. The secondary aim was to consider the potential use of these methods in mental health clinical practice. METHODS: This systematic review follows the PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines and is registered with PROSPERO (Prospective Register of Systematic Reviews; number CRD42019107376). The search was conducted using 4 medical databases (PubMed, Scopus, ScienceDirect, and PsycINFO) with the following keywords: machine learning, data mining, psychiatry, mental health, and mental disorder. The exclusion criteria were as follows: languages other than English, anonymization process, case studies, conference papers, and reviews. No limitations on publication dates were imposed. RESULTS: A total of 327 articles were identified, of which 269 (82.3%) were excluded and 58 (17.7%) were included in the review. The results were organized through a qualitative perspective. Although studies had heterogeneous topics and methods, some themes emerged. Population studies could be grouped into 3 categories: patients included in medical databases, patients who came to the emergency room, and social media users. The main objectives were to extract symptoms, classify severity of illness, compare therapy effectiveness, provide psychopathological clues, and challenge the current nosography. Medical records and social media were the 2 major data sources. With regard to the methods used, preprocessing used the standard methods of NLP and unique identifier extraction dedicated to medical texts. Efficient classifiers were preferred rather than transparent functioning classifiers. Python was the most frequently used platform. CONCLUSIONS: Machine learning and NLP models have been highly topical issues in medicine in recent years and may be considered a new paradigm in medical research. However, these processes tend to confirm clinical hypotheses rather than developing entirely new information, and only one major category of the population (ie, social media users) is an imprecise cohort. Moreover, some language-specific features can improve the performance of NLP methods, and their extension to other languages should be more closely investigated. However, machine learning and NLP techniques provide useful information from unexplored data (ie, patients' daily habits that are usually inaccessible to care providers). Before considering It as an additional tool of mental health care, ethical issues remain and should be discussed in a timely manner. Machine learning and NLP methods may offer multiple perspectives in mental health research but should also be considered as tools to support clinical practice.

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BACKGROUND: The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss. METHODS: Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ2 or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups. RESULTS: One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ2 = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group. CONCLUSIONS: There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.

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INTRODUCTION: Radial head arthroplasty with a smooth-stemmed metallic modular implant is a reliable treatment option for patients with acute unreconstructible radial head fractures, and good clinical outcomes may be expected beyond 5 years of follow-up (Video 1). STEP 1 PREOPERATIVE PLANNING: Obtain a careful history and perform a physical examination along with appropriate imaging to facilitate appropriate treatment decisions. STEP 2 OPERATING ROOM SETUP AND PATIENT POSITIONING: Perform proper operating room setup and patient positioning, as they are required to gain access to all affected structures around the elbow in a safe and efficient manner. STEP 3 APPROACH: Make a midline posterior skin incision with development of a full-thickness lateral fasciocutaneous flap or use a direct lateral incision; the deep interval is determined on the basis of the integrity of the LCL. STEP 4 RADIAL HEAD EXCISION: Remove and preserve all fragments of the radial head for implant sizing. STEP 5 IMPLANT SIZING: Implant a prosthesis that closely replicates the dimensions of the native radial head, which is the primary goal of the procedure. STEP 6 STEM BROACHING: Sequentially broach the canal until good cortical contact is achieved and undersize the definitive stem by 1 mm to allow implant movement within the canal and appropriate articulation with the capitellum. STEP 7 INSERTION OF TRIAL COMPONENTS AND FINAL RADIAL HEAD IMPLANT: With the selected trial in place, assess the radial head diameter, height, and articular congruency. STEP 8 CLOSURE AND REPAIR OF THE LCL: Ensure proper repair of the LCL as it is essential to maintaining or restoring elbow stability. STEP 9 POSTOPERATIVE PROTOCOL: Postoperative rehabilitation depends on the status of the collateral ligaments. RESULTS: In a review of the cases of 55 patients at a mean follow-up of 8 years after radial head arthroplasty with a smooth-stemmed modular metallic prosthesis, Marsh et al.9.

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BACKGROUND: Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. METHODS: The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. RESULTS: At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05). CONCLUSIONS: The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Recent literature has shown that Propionibacterium acnes can be cultured from superficial and deep layers of the shoulder. Our aims were to assess the rate of P. acnes colonization in patients undergoing primary shoulder arthroplasty, to identify patient-related risk factors, and to evaluate the efficacy of our perioperative antisepsis protocol. METHODS: Thirty consecutive patients undergoing primary shoulder arthroplasty were included in our study. Swabs were taken perioperatively (4 superficial and 2 deep wound swabs) and analyzed quantitatively for P. acnes. Cefazolin minimum inhibitory concentration was determined for P. acnes isolates from positive deep cultures. RESULTS: Twenty-two patients (73%) had positive cultures for P. acnes. Male gender (P = .024) and presence of hair (P = .005) had significantly higher rates of P. acnes superficial cultures. Subjects with positive superficial P. acnes cultures (P = .076) and presence of hair with a history of steroid injection (P = .092) were more likely to have deep P. acnes-positive cultures, but this was not statistically significant. Local topical antisepsis measures did not eradicate P. acnes (P = .12). Mean cefazolin minimum inhibitory concentration for P. acnes was 0.32 µg/mL. CONCLUSION: P. acnes is commonly isolated from the skin and deep surgical wounds of patients undergoing primary total shoulder arthroplasty who have not had previous shoulder surgery. Male gender and presence of hair were significant risk factors for P. acnes colonization. Perioperative local topical antisepsis and cefazolin administration were not effective in eliminating P. acnes colonization.

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For more than 60 years, total elbow arthroplasty (TEA) has been successfully used to treat a variety of elbow conditions. Although first designed to treat older patients with rheumatoid arthritis, the indications have expanded to include younger, higher-demand patients with a broad range of elbow pathology. Two groups of TEA currently exist. The first group includes linked or semiconstrained elbows with a mechanical connection between the humeral and ulnar components that prevents disassociation. These implants do not rely on muscular or ligamentous tissues for stability. The second group includes unlinked implants that have no physical connection between the humeral and ulnar components. They rely on bearing surface architecture as well as soft-tissue integrity for elbow stability. Critical to the success of unlinked implants is a thorough preoperative evaluation of elbow stability, including bone stock, collateral ligament integrity, and periarticular muscle function. Unlinked implants should apply less strain to the bone-cement-implant interfaces, which may theoretically decrease rates of bearing wear and aseptic loosening. For this reason, some surgeons prefer unlinked implants for younger, higher-demand patients. To date, unlinked implants have not been clinically shown to improve survivorship compared with linked devices. No prospective randomized trials comparing linked and unlinked TEAs are currently available. Historically, unlinked implants have had higher revision rates, mostly caused by instability and early design flaws. More recent series have shown no significant differences in outcomes compared with linked devices. Unlinked TEA provides reliable pain relief and improved range of motion for patients with a variety of elbow disorders. Diligent patient selection and careful surgical technique are of utmost importance when considering an unlinked TEA as a treatment option. The recent development of convertible implants now allows surgeons to make intraoperative decisions regarding elbow stability and convert to a linked implant without revising the stems.

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