Background:Subcoracoid impingement has been implicated as a cause of anterior shoulder pain and subscapularis tendon tears.Purpose/Hypothesis:The purpose of this study was to evaluate the bony anatomy of the coracoid process and the subcoracoid space. We hypothesized that age-related changes that may contribute to subcoracoid impingement occur in the subcoracoid space.Study Design:Descriptive laboratory study.Methods:In total, 418 skeletal shoulder specimens were included in this study. We utilized 214 shoulders from a young cohort (25-35 years of age) and 204 shoulders from an older cohort (>55 years of age) for comparison. We evaluated several morphological characteristics of the coracoid process and the subcoracoid space: coracoid width, coracoid shape, coracoid thickness, and subcoracoid distance. Each coracoid was observed for the presence of spurring or other morphological changes.Results:The mean anteroposterior (AP) thickness of the coracoid tip was 7.9 and 9.4 mm in our young female and male cohorts, respectively, while the mean AP thickness was 8.1 and 9.7 mm in our older female and male cohorts, respectively. The coracoid tip was hooked in 31 of 108 young female shoulders compared with 55 of 102 older female shoulders, and the coracoid tip was hooked in 25 of 106 young male shoulders compared with 45 of 102 older male shoulders. The mean subcoracoid distance in neutral rotation was 14.8 and 12.5 mm in young and older female shoulders, respectively, while the mean subcoracoid distance in internal rotation in these same cohorts was 8.7 and 7.0 mm, respectively. The mean subcoracoid distance in neutral rotation was 14.8 and 13.3 mm in young and older male shoulders, respectively, while the mean subcoracoid distance in internal rotation was 8.6 and 8.1 mm in young and older male shoulders, respectively.Conclusion:The principal findings of our study demonstrate that anatomic changes implicated in subcoracoid impingement may be developmental and worsen with age. The subcoracoid space was narrower in our older cohort of shoulders. Additionally, these older shoulders also had a greater AP width and a more hooked coracoid compared with young shoulders.Clinical Relevance:Narrowing of the subcoracoid space has been shown to be implicated as a cause of anterior shoulder pain and subscapularis tendon tears. This is the first study to show that the morphological changes implicated in subcoracoid impingement become more prevalent with age. This may help to explain the increasing prevalence of subscapularis tendon tears in older patients. Furthermore, subcoracoid decompression may be seen as an option for older patients with anterior shoulder pain and subscapularis tendon tears.

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Fracture mapping has been used in the understanding of injury patterns in different bones. To our knowledge, there are no applications of this technique using three-dimensional (3D) morphologic fracture characteristics. Previously, scapula fractures were mapped by transferring information from 3D computed tomography to a two-dimensional (2D) template. Cole et al. determined that 3D Computerized Tomography (CT) scans were more reliable compared to plain radiographs in terms of scapular angulation, translation, and glenopolar angle measurements. Thus, we hypothesized that if there is a difference between fracture lines drawn in 3D and in 2D, then the 3D mapping would yield more accurate fracture patterns. We completed a retrospective, comparative study (evidence level III) utilizing CT imaging from a single center scapular registry. We studied ten patients with scapula fractures in whom bilateral CT scans were obtained. Fractures were mapped both two and three-dimensionally, and we measured deviations between the fracture lines that were drawn with each approach. The measured deviations ranged from 10.4 mm to 28.0 mm when comparing 2D versus 3D techniques, with the mean deviation being 4.0 mm and 10.4 mm, respectively. Half of the 2D renderings possessed hidden fracture lines that were later revealed on 3D imaging. Three-dimensional renderings were more accurate when compared to 2D fracture mapping methods. This more accurate technique will allow for better understanding of 3D morphology and provide a basis for future fracture mapping in any bone. Accurate mapping is important because surgical approach, reduction, fixation, and implant design and selection are based on fracture patterns. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:265-271, 2018.

Background: An increasing emphasis has been placed on developing value-based care delivery systems in orthopaedics to combat rising health care costs. The goal of these systems is to both measure and improve the provisional value of care. Patient-level value analysis creates a mechanism to quantify and optimize value within a procedure, in contrast to traditional methods, which only measures value. The purpose of this study was to develop a patient-level value analysis model and determine the efficacy of this model to improve value in orthopaedic care. Methods: Patients treated operatively for isolated closed ankle fractures at a single level 1 trauma center were prospectively identified. Short musculoskeletal function assessment was collected at the time of the initial clinical presentation and 6 months postoperatively. The cost of care was determined using time-driven activity-based costing, which included personnel, supplies, length of stay, implants, pharmacy, and radiology. Value was defined as each patient's change in the outcome score divided by their cost as determined by time-driven activity-based costing. A multiple linear regression was performed to determine which aspects of care significantly predicted value. Results: Forty-nine patients met inclusion/exclusion criteria. The multiple linear regression indicated treatment by physician D (β = −0.135, P = 0.04) and inpatient stay (β = −0.468, P < 0.01) were predictors of lesser value and represent areas for potential care pathway and value improvement. Conclusions: Patient-level value analysis represents a paradigm shift in the quantification of value. We recommend surgeons, practices, and health care systems begin implementing a system to quantify and optimize the value of care provided. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

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Objectives: To assess surgical and functional outcomes in a cohort of patients having surgically reconstructed acromion nonunions or severely comminuted acute fracture patterns treated with a variable angle, locking mesh plate with a matrix of screw options.Design: Retrospective case series.Setting: Level I trauma center.Patients: Between 2012 and 2017, 10 patients, 4 patients with acromion nonunions and 6 patients with severely comminuted acromion fractures presented to a single institution and underwent surgical treatment.Intervention: Surgical repair of complex acromion fractures and nonunions utilizing a 2.4/2.7 locking mesh plate (Depuy-Synthes) with bone grafting (nonunions).Main Outcome Measurements: Primary outcome measures include range of motion; strength; Disabilities of the Arm, Shoulder, and Hand; and Short Form 36 Health Survey.Results: Seven of 10 patients (70%) achieved 1 year follow-up, mean 23.3 months (range, 12 to 46 mo). Nine of 10 patients achieved union following the index reconstruction procedure and 1 patient achieved union after revision of failed mesh plate fixation. At final follow-up, the mean Disabilities of the Arm, Shoulder, and Hand score was 20.0 (11.2 in fracture group and 31.6 in nonunion group) and mean mental and physical component Short Form 36 scores were 51.4 and 42.9, respectively.Conclusions: A variable angle, locking mesh plate may be a useful implant choice for complex nonunions and severely comminuted fracture patterns of the acromion process. In this series, union rate and perioperative complications were acceptable in extreme fracture variants.