Subscapularis tenotomy (SST) has been the preferred approach for shoulder arthroplasty for decades but recent controversy has propelled lesser tuberosity osteotomy (LTO) as a potential alternative. Early work by Gerber suggested improved healing and better outcomes with LTO although subscapularis muscular atrophy occurred in this group as well with unknown long-term implications. However, we previously performed a biomechanical study showing that some of the poor results following tenotomy may have been due to historic non-anatomic repair techniques. Surgical technique is critical to allow anatomic healing – this is true of both SST or LTO techniques. A recent meta-analysis of biomechanical cadaveric studies showed that LTO was stronger to SST at “time-zero” with respect to load to failure but there were no significant differences in cyclic displacement.

A recent study evaluated neurodiagnostic, functional, and radiographic outcomes in 30 patients with shoulder arthroplasty who had SST. The authors found that the EMG findings were normal in 15 patients but abnormal in the other 15 and that these abnormalities occurred in 5 muscle groups (not just the subscapularis). In another study, patient outcomes were inferior in those patients who had documented subscapularis dysfunction following SST compared to patients who had LTO (none of whom had subscap dysfunction). The literature is not clear, however, on ultimate outcomes based on subscapularis dysfunction post-arthroplasty with some studies showing no difference and others showing significant differences.

Pain management following surgery continues to challenge patients, physician-extenders, and surgeons. A recent survey of 300 patients following surgery found that 86% experienced pain following surgery with 75% describing moderate or severe pain. Pain management in 2017 has to better address patient's needs as Pain has become the “5th Vital Sign” and is used in many patient reported outcomes (for better or worse). Multimodal therapy has been defined as “Synchronous administration of ≥ 2 pharmacological agents or approaches, each with a distinct mechanism of action”.

Mounting evidence supports the use of a multimodal approach to peri-operative pain management in all surgical subspecialties. A recent systematic review of intravenous ketamine showed a reduction total opioid consumption and an increase in the time to first analgesic dose needed across all studies. Gabapentin and pregabalin have both been shown to dramatically reduce the use of opioid consumption by 30%. We have worked with our anesthesia team and developed a multimodal analgesia program that includes ketorolac 10mg 3 tabs po qd × 3 days, then 10mg 2 tabs po × 2 days; gabapentin 300mg (<65 year old) or 100mg (>65 year old) 3 tabs po × 3 days; oxycodone 5mg po q 4–6 hours prn breakthrough pain and Tylenol 500mg 1–2 tabs po q 6 hours prn.

Management of 4-part fractures of the proximal humerus continues to challenge orthopaedic surgeons, shoulder surgeons, and trauma surgeons. Truly displaced 4-part fractures typically require surgery if the patient is medically able to undergo a surgical procedure. However, outcomes following surgery are not always as predictable as we would like. Results following hemiarthroplasty have led to more predictable pain relief than predictable functional recovery relying exclusively on the fate of tuberosity healing. Tuberosity healing failure leads to nearly universal catastrophic results with pain, dysfunction, and pseudoparalysis. Furthermore, conversion of failed hemiarthroplasty to reverse total shoulder arthroplasty leads to the highest incidence of complications and poorest outcomes of all groups of patients undergoing reverse total shoulder replacement. This is countered by the knowledge that if tuberosity healing occurs the outcome can be reliable with regard to pain relief and functional restoration.

Reverse total shoulder arthroplasty, on the other hand, has emerged as a preferred surgical option for many surgeons due to the issues following hemiarthroplasty. The increased prevalence of RTSA for the management of 4-part fractures has come without overwhelming evidence that outcomes are superior especially in light of the increased cost, life-time weight bearing restrictions, and uncertain long-term durability. Long-term follow-up of patients treated with RTSA for 4-part fracture has shown concerning degradation of function and outcomes and remains a valid concern about the long-term durability. We must remain diligent therefore in continuing to better understand which fractures should be treated non-operatively and those that may be amenable to anatomic hemiarthroplasty and finally those which may be better served by using a reverse total shoulder replacement.

Purpose: Currently, approximately 90% of the 620 graduating orthopaedic residents are planning on entering a post-graduate fellowship. Since January of 2005, two of the largest orthopaedic fellowship match programs, Sports Medicine and Spine Surgery, were dissolved by the NRMP due to gradual decline and reduced participation leaving approximately 70% of applicants in a non-match, decentralized system.

Method: An on-line survey was designed by orthopaedic leadership of the AOA with the help of two Harvard business school “match” economists. The survey was administered to PGY-4 orthopaedic residents participating in the AOA Resident Leadership Forum (RLF) of 2007. This data was used as the cornerstone of the RLF for 2007, where the residents deliberated the results of the survey and formulated a brief recommendation list. The survey responses were then tabulated electronically and subjected to market analysis.

Results: Sixty-five out of 112 (58%) RLF Residents answered the on-line survey, while 93 (83%) answered audience response questions at the RLF. Thirty percent of residents (19/64) did not have enough time and exposure in their residency to decide which subspecialty to enter. They felt the ideal interview period should be held from January through March of the PGY-4 year. Over 50% of residents felt pressure to accept early offers, had to accept an offer before finishing interviewing or accepted their first offer. Sixty-eight percent (43/64) had to respond to an offer in less than one week. Seventy-six percent (31/47) felt they were given inadequate time to accept or reject offers. Thirty-six percent (17/47) asked for more time to think about an offer. Over 50% (33/65) accepted their first offer and 8% (5/47) had an offer withdrawn because they did not give a response within a designated time frame (exploded offer). Residents cancelled a mean of 2.7 interviews per resident (range 0–9). Eighty-percent (50/64) thought a match would be better than the current system, if most programs would adhere to it. Approximately 47% (41/88) of the residents favored a more centralized process involving all orthopedic surgery fellows, while 35% (31/88) favored a subspecialty based system.

Conclusion: The RLF deliberations can be summarized as follows:

The current fellowship hiring process is decentralized, poorly functioning, unraveled and generally unfair. It creates anxiety for residents, residency directors, and fellowship directors alike. Residents are facing exploding offers, limited exposure to fellowship programs and, ultimately, an unraveling hiring market.