Dr. Lin examined the natural history of patients returning to driving after arthroscopic rotator cuff repairs. Using a prospective cohort from a single surgeon, this investigation sought to describe patients' post-operative behavior, their perception of driving ability (both safety and maneuverability), and the prevalence of narcotic use. Forty-seven of the sixty-seven patients who underwent arthroscopic RTC meeting inclusion criteria were enrolled. Enrolled patients completed a survey at their respective fourmonth follow-up appointments. Endpoints for the study included the distribution of when patients returned to driving, how long it took drivers to feel safe, driver perception of maneuverability, period of narcotics use after surgery, and the prevalence of pain, weakness, and sling use in the driving population. The significance of the impact of narcotics use, sling use, weakness, and pain to effect patient perception of safety and driving maneuverability was also explored. He found significant variability in the time period patients waited before return to driving, and there was no consistent pattern of patient perception of safety when stratified by the amount of time patients waited to drive. . Drivers reporting weakness were 3.0 times more likely to feel unsafe driving and 2.8 times more likely to have trouble maneuvering their vehicles. Drivers reporting pain were 2.2 times more likely to have trouble maneuvering their vehicles. Neither narcotics use nor sling use was found to have a significant impact on patient perception of safety or driving maneuverability. Dr. Lin concluded the time from surgery does serve to guide when patients can safely return to driving. Clinical measures of pain and weakness should be incorporated into discussions with patients on when patients are safe to return to driving again.

Dr. Oh discussed Dr. Lin's paper on rotator cuff injuries and return to driving and noted the use of pain as a surrogate for safe driving. He posed the question of the role of the orthopedic surgeon for determining safe driving. Dr. Weinstein stressed the use of simulation centers for clearing drivers to return to the road after rotator cuff surgery.

Dr. Crall explored the question of what is the optimal treatment strategy - primary arthroscopic stabilization versus nonoperative management - for primary traumatic anterior glenohumeral dislocations. He attempted to answer this question by employing gaming theory with an expected-value decision analysis. The probabilities of the potential outcomes after nonoperative and arthroscopic treatment of a first time traumatic anterior glenohumeral dislocation factors were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. Sensitivity analyses were used to determine the effect on decisionmaking of varying outcome probabilities and utilities. Dr. Crall showed that non-operative treatment was associated with a utility value of 5.9 and early arthroscopic surgery a value of 7.6. When parameters were varied in sensitivity analysis, it was found that when the rate of recurrence following nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, non-operative treatment is the preferred management strategy. Dr. Crall concluded that arthroscopic stabilization of primary anterior shoulder dislocations is the preferred strategy except when it is determined the likelihood of recurrent instability is low after conservative care or when an informed patient has an aversion to surgery

Dr. Gill discussed Dr. Crall's decision analysis for treatment after glenohumeral dislocation. He noted that this is one data point on the positive side for operative treatment. He also warned against over-using evidencebased decision to solely drive treatment. He stressed using it as a framework for understanding the treatment options. Dr. Weinstein questioned the use of a sole DRG for shoulder repair for determining outcomes. Dr. Warner posed the question of how this will drive Tim’s decision making from here on out. Dr. Springfield raised the question of how the model changes with recurrent dislocations.

Dr. Bauer investigated the relatively unknown incidence and risk factors of heterotopic ossification (HO). She used a matched case-control retrospective design. Potential risk factors and patient characteristics were identified using our fracture registry. Dr. Bauer identified 729 patients with elbow fractures, of which 60 (8%) developed HO. Olecranon fractures had the lowest incidence at 0.6% and floating elbows (fractures on both sides of the joint) the highest incidence at 45.5%. Risk factors identified included number of days to elbow mobilization after surgery, postoperative infection requiring reoperation, and presence of hematoma postoperatively. Based on this data she postulated that earlier mobilization of patients following operative management of elbow fractures may decrease the rate of HO.

Dr. Mudgal congratulated Dr. Bauer on a comprehensive but not cumbersome study, noting that this will add to what is known about HO at the elbow. He raised the question of isolated radial head fractures and the risk of HO and proposed a new definition of HO based on clinical and radiographic findings. Dr. Weinstein posed the question of radiation or pharmacological prophylaxis in the patients. Dr. OH noted a study at Mayo which linked the number of elbow cases performed by the surgeon and the risk of developing HO.