Dr. Costouros specializes in the comprehensive treatment of shoulder disorders using both arthroscopic and open surgical techniques. He is Board-Certified by the American Board of Orthopedic Surgery, a Fellow of the American Academy of Orthopaedic Surgeons and the American College of Surgeons, and has a Certificate of Added Qualification (CAQ) in Sports Medicine. He has particular expertise in traditional and reverse shoulder replacements, stemless shoulder arthroplasty, rotator cuff repair, the treatment of shoulder instability, revision shoulder surgery, and the treatment of sports injuries and fractures of the clavicle and shoulder girdle. He has developed innovative techniques and devices which are FDA-approved and in clinical use worldwide.

He is Past President of the Northern California Orthopaedic Society, Northern California Chapter of the Western Orthopaedic Association, and the Leroy C. Abbott Orthopaedic Society. He is an active member of the society of American Shoulder and Elbow Surgeons (ASES), American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), European Shoulder and Elbow Society (SECEC), and International Society of Arthroscopy, Knee Surgery, and Sports Medicine (ISAKOS). His research is focused on enhancing clinical outcomes using molecular mediators, stem cells, biologics, and the design of state-of-the-art implants used in shoulder surgery.

Clinical Focus

  • Orthopaedic Surgery and Sports Medicine
  • Orthopaedic Surgery
  • Shoulder Disorders
  • Shoulder Surgery
  • Shoulder Fractures
  • Rotator Cuff Tears
  • Shoulder Joint Replacement
  • Shoulder Instability
  • Shoulder Labral Tears
  • Clavicle Fractures
  • Adhesive Capsulitis
  • Shoulder Infection
  • Reverse Shoulder Replacement
  • Total Shoulder Replacement
  • Stemless Shoulder Replacement
  • Sports Injury of the Shoulder
  • Bankart Tear
  • Throwing Injury of the Shoulder

Academic Appointments

Administrative Appointments

  • Chair, Instructional Course Lectures Committee, Shoulder & Elbow Sessions, American Academy of Orthopaedic Surgeons 85th and 86th Annual Meeting (2018 - Present)
  • American Shoulder & Elbow Surgeons Recertification Examination Committee, American Board of Orthopaedic Surgery, American Academy of Orthopaedic Surgery (2017 - Present)
  • Grants Committee, American Shoulder & Elbow Surgeons Foundation (ASES) (2017 - Present)
  • Standard Setting Exercise Committee, American Board of Orthopaedic Surgery, Certification/Recertification Examination in Sports Medicine (2017 - Present)
  • Board of Directors, The Codman Shoulder Society (CSS) (2016 - Present)
  • Membership Committee, American Shoulder & Elbow Surgeons (ASES) (2016 - Present)
  • International Committee, Arthroscopy Association of North America (AANA) (2014 - Present)
  • Medical Advisory Committee, United Healthcare (UHC) (2014 - Present)
  • Admissions Committee, Stanford University School of Medicine (2012 - Present)
  • Bylaws Committee, Arthroscopy Association of North America (AANA) (2012 - Present)
  • Program Committee, Shoulder & Elbow Sessions, American Academy of Orthopaedic Surgeons Annual Meeting (2012 - 2016)
  • President, Leroy C. Abbott Orthopaedic Society (UC San Francisco) (2011 - 2013)
  • President, Northern California Chapter of the Western Orthopaedic Association (NCCWOA) (2011 - 2012)
  • President, Northern California Orthopaedic Society (NCOS) (2011 - 2012)
  • Board of Directors, Leroy C. Abbott Orthopaedic Society (UC San Francisco) (2008 - Present)
  • Medical Director, Graduate School of Athletic Training, San Jose State University (2008 - 2013)
  • Adjunct Professor, Graduate School of Athletic Training, San Jose State University (2007 - 2013)
  • Adjunct Professor, Department of Kinesiology, San Jose State University (2006 - 2013)
  • Team Physician, San Jose State University Athletics (2006 - 2012)
  • Admissions Committee, University of California San Francisco (UCSF) School of Medicine (1995 - 1998)

Honors & Awards

  • Departmental Honors, Stanford University, Department of Biological Sciences (1994)
  • Firestone Honorary Research Fellowship, University of California San Francisco (UCSF) School of Medicine (1995)
  • Alumni Scholarship for Academic Excellence, University of California San Francisco (UCSF) School of Medicine (1997)
  • Research Fellowship, Arthroscopy Association of North America (AANA) (2002)
  • Award for Excellence in Basic Science Research, Leroy C. Abbott Orthopaedic Society, University of California San Francisco (UCSF) (2002)
  • Research Poster of the Year, Arthroscopy Association of North America (AANA) (2003)
  • Award for Excellence in Basic Science Research, Leroy C. Abbott Orthopaedic Society, University of California San Francisco (UCSF) (2004)
  • Award for Outstanding Contribution to Arthroscopic Shoulder Surgery, Smith & Nephew Endoscopy (2005)
  • Research Award, Arthroscopy Association of North America (AANA) (2006)
  • Japanese Orthopaedic Association (JOA) Honorary International Traveling Fellow, American Orthopaedic Association (AOA) (2011)
  • Young Investigator Award, Western Orthopaedic Association (WOA) (2013)
  • Leaders in Total Joint Replacement: Generation Next Award, Orthopaedics Today (2013)

Professional Education

  • Fellowship:Harvard Hand and Upper Extremity Fellowship (2004) MA
  • Residency:UCSF Dept of Orthopedic Surgery (2004) CA
  • Internship:UCSF Dept of General Surgery (1999) CA
  • Medical Education:University of California at San Francisco School of Medicine (1998) CA
  • Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (2008)
  • Board Certification: Sports Medicine, American Board of Orthopaedic Surgery (2011)
  • Fellowship, University of Zurich, Balgrist Hospital, Shoulder and Elbow Surgery (2005)
  • Fellowship, University of California San Francisco, Department of Orthopaedic Surgery, Cartilage Injury, Arthritis (2002)
  • B.S. with Honors, Stanford University, Biological Sciences (1994)

Community and International Work

  • Orthopaedic Overseas, South Africa, Central and South America


    Orthopaedic Surgery Volunteerism

    Partnering Organization(s)

    Health Volunteers Overseas

    Populations Served

    Third World



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Dr. Costouros has devoted his entire career to mastering the comprehensive treatment of shoulder disorders. He specializes in the arthroscopic and open treatment of shoulder disorders derived from sports injuries, arthritis, fractures, compressive neuropathies, and failed prior surgeries. He has made significant award-winning research discoveries in the molecular etiology and treatment of arthritis and cartilage injuries.

He has special expertise in the reverse total shoulder replacement, management of complex rotator cuff tears, revision surgery, tendon transfers, fractures of the shoulder girdle including the proximal humerus and clavicle, and the treatment of sports-related disorders and instability of the shoulder in overhead athletes using arthroscopic techniques.

His research focuses on improving our understanding of cartilage injury and arthritis at the cellular level, specifically the development of methods to modulate programmed cell death or apoptosis. He also is involved in the development of cell-based strategies in improving outcomes following rotator cuff repair and better understanding the causes of rotator cuff disease.

Dr. Costouros has designed and continues to develop shoulder joint replacement devices and tools for improved precision and surgical navigation which will enhance clinical outcomes following shoulder arthroplasty and longevity of these devices. In addition, he continues to be interested in the development of instruments to analyze surgical outcomes and the creation of registries which allow surgeons to better understand patient-specific outcomes, implant longevity, wear mechanisms, and how surgeons can consistently deliver the best results following shoulder surgery.

Clinical Trials

  • Arthrex Eclipse™ Shoulder Prosthesis Recruiting

    A Prospective, Randomized, Multicenter Study comparing the Safety and Effectiveness of Arthrex's Eclipse™ Shoulder to the Univers™ II Shoulder Prosthesis in patients with a degenerative joint disease.

    View full details

  • Clinical Outcomes in Shoulder Hemi-arthroplasty Using a PyC Spherical Interpositional Implant Not Recruiting

    The INSPYRE implant is a new range of shoulder hemi-arthroplasty device. It consists of a Pyrocarbon spherical interpositional implant and is indicated in primary surgery to relieve severe pain or significant disability caused by degenerative pathologies. The rotator cuff must be functional. The aim of this study is to prospectively collect data from consecutive series to implement a Post Marketing Surveillance plan.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Sidus Stem-Free Shoulder IDE Study Not Recruiting

    The purpose of this study is to determine if Sidus stem-free shoulder system is safe and effective when used in total shoulder replacement.

    Stanford is currently not accepting patients for this trial.

    View full details

2019-20 Courses

All Publications

  • Successful reversal of phrenic nerve blockade following washout of interscalene nerve block as demonstrated by ultrasonographic diaphragmatic excursion. Journal of clinical anesthesia Ngai, L. K., Ma, W., Costouros, J. G., Cheung, E. V., Horn, J., Tsui, B. C. 2019; 59: 46–48

    View details for DOI 10.1016/j.jclinane.2019.06.022

    View details for PubMedID 31212125

  • Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery Secondary Analysis of a Randomized Clinical Trial JAMA NETWORK OPEN Hah, J. M., Cramer, E., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2019; 2 (3)
  • Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery: Secondary Analysis of a Randomized Clinical Trial. JAMA network open Hah, J. M., Cramer, E., Hilmoe, H., Schmidt, P., McCue, R., Trafton, J., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., Mackey, S. C., Carroll, I. 2019; 2 (3): e190168


    Importance: Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable.Objective: To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes.Design, Setting, and Participants: A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018.Interventions: Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours.Main Outcomes and Measures: A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery.Results: Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P<.001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P<.001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P=.89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P=.008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P<.001), a history of alcohol or drug abuse treatment (ARR,1.90; 95% CI, 1.42-2.53; P<.001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P=.03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P<.001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P<.001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P<.001).Conclusions and Relevance: This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings.Trial Registration: Identifier: NCT01067144.

    View details for PubMedID 30821824

  • Instability after reverse total shoulder arthroplasty JOURNAL OF SHOULDER AND ELBOW SURGERY Cheung, E. V., Sarkissian, E. J., Sox-Harris, A., Comer, G. C., Saleh, J. R., Diaz, R., Costouros, J. G. 2018; 27 (11): 1946–52
  • Biologics for Rotator Cuff Repair: A Critical Analysis Review. JBJS reviews Smith, K. M., Le, A. D., Costouros, J. G., Dragoo, J. L. 2018

    View details for PubMedID 30362970

  • Instability after reverse total shoulder arthroplasty. Journal of shoulder and elbow surgery Cheung, E. V., Sarkissian, E. J., Sox-Harris, A., Comer, G. C., Saleh, J. R., Diaz, R., Costouros, J. G. 2018


    BACKGROUND: This study evaluated patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability.METHODS: Dislocation and nondislocation cohorts were established for analysis in 119 patients who had undergone RTSA at our institution between 2011 and 2014. Preoperative history and parameters pertaining to RTSA design were evaluated for correlation with instability. A logistic regression model was used to analyze independent predictors.RESULTS: Eleven patients (9.2%) demonstrated instability in the early postoperative period. Dislocations occurred at an average of 8 weeks postoperatively (range, 3 days-5 months). The mean follow-up of all patients was 28 months (range, 6-106 months). Postoperative instability was associated with male gender, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability. In addition, 5 of the 11 patients (45%) in the instability cohort sustained a second dislocation requiring another operation.CONCLUSIONS: Redislocation after revision surgery for the initial dislocation was an unexpected and alarming finding. Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of patients of our cohort and required another revision with a larger glenosphere and thicker humeral inserts. Initial instability after RTSA must be carefully managed, especially in the revision and post-traumatic setting. Exchange to a thicker polyethylene insert only carries a higher risk of recurrent instability.

    View details for PubMedID 29934280

  • A Treatment-Based Algorithm for the Management of Type-II SLAP Tears. The open orthopaedics journal Johannsen, A. M., Costouros, J. G. 2018; 12: 282–87


    Background: The management of Type-II superior labral tears (SLAP) of the shoulder remains a controversial topic. Treatment ranges from non-operative management to surgical management including SLAP repair, biceps tenotomy, and biceps tenodesis. An optimal treatment algorithm has yet to reach universal acceptance.Objective: The goal of this paper was to provide a treatment algorithm for the management of Type-II SLAP tears based on current literature and expert opinion.Method: Current literature was reviewed and expert opinion was reported to develop a comprehensive treatment protocol for patients based on age, activity level, and pathology.Results: Operative management of type-II SLAP tears yields good to excellent outcomes when proper indications are followed. Biceps tenodesis may produce more reliable pain relief and functional improvement when compared to primary SLAP repair in patients over the age of 40.Conclusion: When non-operative management of Type-II SLAP tears fails, operative management yields good to excellent outcomes in most patients. Primary SLAP repair should be performed in patients under the age of 40 with no evidence of proximal biceps pathology, while biceps tenodesis can provide consistent pain relief and return to activity in patients over the age of 40 or with significant proximal biceps pathology. Tenotomy should be reserved for elderly or low demand individuals.

    View details for PubMedID 30197709

  • Simultaneous bilateral resection total shoulder arthroplasty with anatomic antibiotic cement spacer retention. JSES open access Ueda, Y., Comer, G. C., Saleh, J. R., Costouros, J. G. 2017; 1 (3): 129–32

    View details for PubMedID 30675554

  • Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA surgery Hah, J., Mackey, S. C., Schmidt, P., McCue, R., Humphreys, K., Trafton, J., Efron, B., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J., Curtin, C., Carroll, I. 2017


    Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further Identifier: NCT01067144.

    View details for PubMedID 29238824

  • Is Ultrasound Guidance Needed for Shoulder Injections? PM&R Finnoff, J. T., Costouros, J. G., Kennedy, D. J. 2015; 7 (4): 435–42

    View details for PubMedID 25890640

  • Inhibition of Chondrocyte and Synovial Cell Death After Exposure to Commonly Used Anesthetics Chondrocyte Apoptosis After Anesthetics AMERICAN JOURNAL OF SPORTS MEDICINE Rao, A. J., Johnston, T. R., Harris, A. H., Smith, R. L., Costouros, J. G. 2014; 42 (1): 50-58


    An intra-articular injection of local anesthetics is a common procedure for diagnostic and therapeutic purposes. It has been shown that these agents are toxic to articular cartilage and synovial tissue in a dose- and time-dependent fashion, and in some cases, they may lead to postarthroscopic glenohumeral chondrolysis (PAGCL). However, the role of apoptosis in cell death is still unclear, and the potential role of apoptosis inhibition in minimizing chondrocyte and synovial cell death has not been reported.(1) To quantify the degree of apoptotic cell death in chondrocytes and synovial cells exposed to local anesthetics, and (2) to determine whether caspase inhibition could reduce cell death.Controlled laboratory study.Human chondrocytes and synovial cells were expanded in vitro and exposed to normal saline, 0.5% bupivacaine, 0.5% ropivacaine, 1% lidocaine, or 1:1000 epinephrine for 90 minutes. Apoptosis was then detected at 1, 3, 5, and 7 days after exposure using terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) and immunohistochemistry. Apoptosis was then inhibited using the pan-caspase inhibitor z-vad-fmk. Results were normalized to normal saline controls and analyzed by generalized regression models and pairwise confidence intervals.Analysis of cumulative chondrocyte apoptosis relative to controls after anesthetic exposure demonstrated more than 60% cell death with 0.5% bupivacaine and 1:1000 epinephrine. The greatest chondroprotective effect of caspase inhibition occurred with 0.5% ropivacaine. Similarly, in synovial cells, epinephrine was also very cytotoxic; however, 1% lidocaine induced the most apoptosis. Synovial cells exposed to 0.5% ropivacaine were again most sensitive to protective caspase inhibition.Local anesthetics induce chondrocyte and synovial cell apoptosis in a time-dependent fashion, with peak apoptosis occurring 5 days after exposure. Both chondrocytes and synovial cells are most sensitive to caspase inhibition after exposure to 0.5% ropivacaine.Apoptosis inhibition may be an effective strategy in minimizing chondrocyte and synovial cell death after exposure to anesthetics. Further investigation is clinically warranted.

    View details for DOI 10.1177/0363546513507426

    View details for PubMedID 24166803

  • Risk of Thromboembolism in Shoulder Arthroplasty: Effect of Implant Type and Traumatic Indication CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Navarro, R. A., Inacio, M. C., Burke, M. F., Costouros, J. G., Yian, E. H. 2013; 471 (5): 1576-1581


    Prior research about symptomatic venous thromboembolism (VTE) after shoulder arthroplasty has not determined whether procedure type (hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty) or surgical indication (traumatic or elective) represent risk factors for VTE after shoulder replacement.We therefore asked whether the risk of symptomatic VTE events and mortality within 90 days of shoulder arthroplasty was influenced by (1) procedure type, and (2) surgical indication (traumatic or elective).We performed a retrospective database review of symptomatic VTE events and mortality within 90 days of shoulder arthroplasty in a large (30-hospital) integrated healthcare system over a 5-year period, from January 2005 to December 2009. We compared the likelihood of VTE and death in patients undergoing reverse shoulder arthroplasties (RSAs), total shoulder arthroplasties (TSAs), and hemiarthroplasties (HAs), and we compared the likelihood of VTE and death in patients who underwent elective shoulder arthroplasties with those who underwent shoulder arthroplasty in the setting of acute trauma.In the 2574 eligible shoulder arthroplasties identified during the study period, VTE developed in 1.01% of patients (deep vein thrombosis 0.51% and pulmonary embolism 0.54%). With the numbers available, no differences were observed in rates of VTE or mortality by procedure type. A trend toward increased VTE occurred more frequently in patients having surgery for traumatic indications than after elective surgery (1.71% versus 0.80%; p = 0.055). A higher likelihood of 90-day mortality was observed in trauma patients compared with elective (odds ratio = 7.4; 95% CI, 2.4-25.2).VTE occurred infrequently in this study sample. These data support future risk and benefit assessment of routine pharmacologic VTE prophylaxis in the perioperative treatment of patients undergoing shoulder arthroplasty, especially in all RSA and traumatic HA subsets, where the risk of VTE may be higher.

    View details for DOI 10.1007/s11999-013-2829-6

    View details for Web of Science ID 000316959100026

    View details for PubMedID 23392993

    View details for PubMedCentralID PMC3613522

  • Total shoulder arthroplasty with an uncemented soft-metal-backed glenoid component JOURNAL OF SHOULDER AND ELBOW SURGERY Fucentese, S. F., Costouros, J. G., Kuehnel, S., Gerber, C. 2010; 19 (4): 624-631


    Loosening associated with cemented polyethylene glenoid components is a major concern following total shoulder arthroplasty (TSA). The purpose of this study was to investigate the clinical and radiographic results associated with use of a novel uncemented soft-metal-backed glenoid component (SMBG), with a minimum follow-up of 2 years.Twenty-two patients (19 women) underwent TSA using a uncemented SMBG. The mean age was 68.5 years (range, 49-84). Mean follow-up was 50 months (range, 24-89). Indications for TSA were primary osteoarthritis (10), post-traumatic osteoarthritis (8), steroid-induced avascular necrosis (2), crystalline arthropathy (1), and arthritis secondary to systemic lupus erythematodes (1). Subjective and objective parameters were assessed. Loosening and polyethylene wear were evaluated.Mean absolute Constant scores improved from 29.1 to 65.9 points (P < .001), age- and sex-adjusted Constant scores improved from 40.1 to 87.7% (P < .001), and subjective shoulder values improved from 35% to 75.2% (P < .001). Mean pain scores improved from 4.2 points to 13.1 (P < .001). Three cases had a fractured glenoid component. Only these 3 had a definite loosening. Polyethylene wear was found in 2 cases.Use of an uncemented SMBG component yields controversial results. Osteointegration appears possible and loosening signs have virtually not been observed. Conversely, the current implant can be associated with a high failure rate (13.6%) because of implant fractures despite short follow-up. As loosening seems absent or minimal but implant stability insufficient, design changes need to be performed and tested in view of solving the implant failure problem while preserving the actually excellent bone-implant interface characteristics.

    View details for DOI 10.1016/j.jse.2009.12.021

    View details for Web of Science ID 000278901500022

    View details for PubMedID 20382040

  • Static posterior humeral head subluxation and total shoulder arthroplasty JOURNAL OF SHOULDER AND ELBOW SURGERY Gerber, C., Costouros, J. G., Sukthankar, A., Fucentese, S. F. 2009; 18 (4): 505-510


    Static posterior subluxation of the humeral head (PSH) is often associated with glenohumeral arthritis. It may persist following total shoulder arthroplasty (TSA) and lead to accelerated polyethylene wear and glenoid component loosening. The factors which lead to PSH are poorly understood. The purpose of this study was to test the hypothesis that operative correction of glenoid version during shoulder arthroplasty re-centers the glenohumeral joint; therefore, glenoid replacement may be considered even in cases of osteoarthritis associated with posterior humeral head subluxation.Thirty-three of 124 (27%) consecutive shoulders undergoing primary TSA had static preoperative PSH with a subluxation index of at least 65% determined on standardized computer tomographic scans. Twenty-three of these 33 shoulders were available for clinical and computed tomography follow-up after a minimum of 24 and average of 42 months. Mean preoperative glenoid retroversion was -18 [range, 0 degrees - (-40 degrees)], the subluxation index averaged 71% (range, 65-81%). Glenoid morphology, according to Walch et al, was type B1 in 9 patients, type B2 in 5 patients, and type C in 9 patients. A conventional total shoulder replacement was performed through a deltopectoral interval. Using corrective glenoid reaming, restoration of glenoid version to between 0 degrees and 10 degrees of retroversion was attempted in addition to standard soft tissue release. Humeral head retroversion was replicated from the diseased humeral head as closely as possible.PSH was reversed in 21/23 patients following TSA with an average final subluxation index of 50% (range, 40-68%; P = .001). There was no significant correlation statistically between PSH and preoperative or postoperative glenoid version, humeral torsion, glenoid morphology, or acromio-humeral distance. Mean absolute Constant scores improved from 39 to 78 points, age-adjusted Constant scores improved from 49% to 95% and subjective shoulder values improved from 40% to 89%, which were all statistically significant (P < .0001).PSH is frequently present in shoulders with osteoarthritis. It can be corrected in the majority of shoulders undergoing total shoulder replacement; however, re-centering is not correlated with glenoid version or its correction.Level 4; Case series, treatment study.

    View details for DOI 10.1016/j.jse.2009.03.003

    View details for Web of Science ID 000267812400002

    View details for PubMedID 19481961

  • Teres minor integrity predicts outcome of latissimus dorsi tendon transfer for irreparable rotator cuff tears JOURNAL OF SHOULDER AND ELBOW SURGERY Costouros, J. G., Espinosa, N., Schmid, M. R., Gerber, C. 2007; 16 (6): 727-734


    In patients with irreparable rotator cuff tears, latissimus dorsi tendon transfer (LDTT) can be effective in improving pain and function. However, the results are variable, and the factors that predict good outcomes are poorly understood. The purpose of this study was to investigate whether the integrity of the teres minor musculotendinous unit is predictive of outcome following LDTT. Twenty-two consecutive patients who underwent LDTT for massive, irreparable posterosuperior rotator cuff tears were retrospectively reviewed. Sixteen men and 6 women with a mean age of 58 years (range, 40-68) were analyzed at an average follow-up of 34 months (range, 24-57). Standardized MRI images of all patients were reviewed by 3 independent reviewers. Fatty infiltration of the teres minor was Goutallier stage 0 in 5 patients; stage 1 in 6; stage 2 in 4; stage 3 in 6; and stage 4 in 1. Eleven patients (50%) had partial tears and 2 (9%) had complete tears of the teres minor tendon. Following LDTT, the mean absolute constant score improved from 48 to 62 points (P = .003), age-adjusted constant score improved from 56% to 72% (P = .002), and the subjective shoulder value improved from 24% to 68% (P < .001). Fatty infiltration of the teres minor less than or equal to stage 2 was associated with a better postoperative constant score (67 vs 53, P = .015); age-adjusted constant score (78% vs 59%, P = .012); active external rotation (36 degrees vs 16 degrees , P = .016); and active elevation (143 degrees vs 115 degrees , P = .012) relative to patients with fatty infiltration greater than stage 2. The presence or absence of a tear of the tendon had no significant effect on outcome. In conclusion, when performing LDTT for massive irreparable posterosuperior rotator cuff tears, fatty infiltration of the teres minor should be considered prior to surgery, as it is predictive of outcome.

    View details for DOI 10.1016/j.jse.2007.02.128

    View details for Web of Science ID 000251767800009

    View details for PubMedID 17980629

  • Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Costouros, J. G., Porramatikul, M., Lie, D. T., Warner, J. J. 2007; 23 (11): 1152-1161


    The purpose of this study was to study the prevalence of suprascapular neuropathy (SSN) in the setting of massive rotator cuff tears and to determine if arthroscopic rotator cuff repair, even if partial, was associated with reversal of SSN and clinical improvement in pain and function.Over a 13-month period, 26 of 216 patients with rotator cuff tears treated operatively were identified to have massive tears associated with retraction and moderate to severe fatty infiltration of the supraspinatus and infraspinatus muscles. All patients had pain and marked weakness in abduction and external rotation which did not improve with conservative treatment. Electrodiagnostic electromyographic/nerve conduction velocity (EMG/NCV) evaluation, as well as pre- and postoperative questionnaire and physical examination, were performed. An arthroscopic repair, either partial or complete, was performed on patients identified to have a massive rotator cuff tear in association with SSN.Fourteen of 26 patients with massive rotator cuff tears (54%) were identified to have a peripheral nerve injury. Seven of these 26 (38%) had isolated suprascapular nerve injury, 4 had axillary nerve injury, 2 had an associated upper trunk brachial plexus injury, and 1 had a cervical radiculopathy. All 7 patients with isolated suprascapular injury underwent arthroscopic treatment, 1 of which was not technically reparable at the time of surgery. In the 6 patients who underwent either partial or complete arthroscopic repair, follow-up EMG/NCV after 6 months demonstrated partial or full recovery of the suprascapular nerve palsy that correlated with complete pain relief and marked improvement in function.SSN is found in a significant proportion of patients with massive rotator cuff tears, and is associated with pain and dysfunction. Arthroscopic rotator cuff repair can result in reversal of SSN, which may correlate with substantial improvement in pain and function.Level IV, case series.

    View details for DOI 10.1016/j.arthro.2007.06014

    View details for Web of Science ID 000251145800003

    View details for PubMedID 17986401

  • Preventing chondrocyte programmed cell death caused by iatrogenic injury KNEE Costouros, J. G., Kim, H. T. 2007; 14 (2): 107-111


    Cartilage repair technology is advancing at a rapid pace. However, all techniques share a common weakness-unintentional chondrocyte cell death resulting from cartilage injury that occurs during preparation of the defect site. The loss of chondrocytes at the edge of host cartilage is likely to contribute to failed integration of regenerated tissue or grafts to the surrounding cartilage. Recent studies have demonstrated that "apoptosis", or programmed cell death (PCD), may be responsible for much of the cell death caused by cartilage injury. Theoretically, inhibitors of key pathways responsible for PCD could rescue chondrocytes and improve the results of cartilage repair surgery. The purpose of this study was to test the hypothesis that short-term, intra-articular PCD inhibitor treatment can limit chondrocyte death in vivo following simulated preparation of host cartilage for a repair procedure. A microcurette was used to create full-thickness articular cartilage injuries to the femoral condyles of adult New Zealand White rabbits. Animals received daily intra-articular injections either with a potent PCD inhibitor or with vehicle alone. Treatment with the inhibitor resulted in a significant reduction in the percentage of chondrocytes undergoing PCD compared to controls [treated=10.1+/-2.4%; controls=26.5+/-3.6%; (p=0.0013)]. These results provide proof of concept for the use of PCD inhibitors to enhance the results of cartilage repair surgeries.

    View details for DOI 10.1016/j.knee.2006.10.013

    View details for Web of Science ID 000245307300005

    View details for PubMedID 17174553

  • Trans-cuff portal for arthroscopic posterior capsulorrhaphy ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Costouros, J. G., Clavert, P., Warner, J. J. 2006; 22 (10)


    Arthroscopic repair of posterior shoulder instability is becoming an accepted method of treatment. Most surgeons perform this procedure with the patient in a lateral decubitus position to facilitate access to the posterior glenoid. We have developed an accessory portal placed through the midportion of the rotator cuff that allows easy and complete viewing of the posterior glenohumeral joint when the patient is in a beach chair position and does not require the use of traction. This portal provides a superior-to-inferior view of the posterior glenoid rim and capsule and allows use of anterior and posterior routine portals for posterior Bankart repair. In this study, the technique of posterior labral repair in the beach chair position with use of the trans-cuff portal is described, and preliminary results in 5 patients at an average follow-up of 24 months are presented. Through this approach, we were able to place 3 anchors, with the lowest at the 7 o'clock position (for a right shoulder), in all patients. Mean American Shoulder Elbow Surgeons (ASES) score improved from 53 +/- 15 preoperatively to 87 +/- 8 postoperatively (P < .01). All patients had an excellent result with complete resolution of pain and instability.

    View details for DOI 10.1016/j.arthro.2006.05.013

    View details for Web of Science ID 000241722700021

    View details for PubMedID 17027417

  • Comparison of chondrocyte apoptosis in vivo and in vitro following acute osteochondral injury JOURNAL OF ORTHOPAEDIC RESEARCH Costouros, J. G., Dang, A. C., Kim, H. T. 2004; 22 (3): 678-683


    The objective of the present study was to directly compare levels of chondrocyte apoptosis produced by osteochondral injury in vivo and in vitro. Adult New Zealand White rabbits underwent 2 mm osteochondral drilling of the medial and lateral femoral condyles of a single hind limb. Animals were euthanized, and specimens were harvested at 0, 2, 4, 7, 10, and 14 days following injury. At the time of euthanasia, identical injuries were created in the femoral condyles of the contralateral hind limb. These condyles were maintained in vitro under standard tissue culture conditions until harvesting at time points corresponding to the in vivo specimens (i.e. after 0, 2, 4, 7, 10 and 14 days in culture). The extent of apoptosis in the in vivo and in vitro specimens was quantified by TUNEL analysis. The amount and distribution of TUNEL positive cells followed similar patterns in both in vivo and in vitro specimens with a maximal percentage of apoptotic chondrocytes observed on post-injury day 4. On post-injury day 4, in vivo specimens displayed a statistically significant increased overall level of apoptosis compared to in vitro specimens [in vivo=32.5+/-8.6%; in vitro=22.2+/-4.8%; (p=0.03)]. These experiments suggest that the majority of programmed cell death observed after osteochondral injury can be attributed to processes intrinsic to the cartilage itself; however, additional factors present within the acutely traumatized joint also appear to potentiate chondrocyte apoptosis following injury.

    View details for DOI 10.1016/j.orthres.2003.10.008

    View details for Web of Science ID 000221200800032

    View details for PubMedID 15099652

  • Congenital diplopodia PEDIATRIC RADIOLOGY Brower, J. S., Wootton-Gorges, S. L., Costouros, J. G., Boakes, J., Greenspan, A. 2003; 33 (11): 797-799


    Diplopodia, or duplicated foot, is a rare congenital anomaly. It differs from polydactyly in that supernumerary metatarsal and tarsal bones are present as well as extra digits. Only a few cases of this anomaly have been reported in the literature to date. We present a newborn male without intrauterine teratogen exposure who was born with a duplicate foot of the left lower extremity and imperforate anus.

    View details for DOI 10.1007/s00247-003-1017-3

    View details for Web of Science ID 000186038600011

    View details for PubMedID 12961041

  • Inhibition of chondrocyte apoptosis in vivo following acute osteochondral injury OSTEOARTHRITIS AND CARTILAGE Costouros, J. G., Dang, A. C., Kim, H. T. 2003; 11 (10): 756-759
  • Return of motion after simultaneous repair of displaced bucket-handle meniscal tears and anterior cruciate ligament reconstruction ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Costouros, J. G., Raineri, G. R., Cannon, W. D. 1999; 15 (2): 192-196


    Patients with displaced bucket-handle (DBH) meniscal tears in anterior cruciate ligament (ACL)-deficient knees are prone to flexion contracture following meniscal repair and simultaneous ACL reconstruction. It has been suggested that ACL reconstruction be delayed until full range of motion has returned after the meniscal repair. A retrospective analysis was performed comparing the return of extension in patients undergoing simultaneous ACL reconstruction and repair of DBH tears (group A) versus a control group of patients with non-DBH tears (group B). Age, sex, body mass index, duration of time from injury to surgery, and preoperative extension were also compared between groups and evaluated for their significance as risk factors. Patients in group A achieved recovery to -5 degrees and 0 degrees of extension 22% and 35% more slowly, respectively, when compared with group B. These differences were not statistically significant. Female patients tended to heal more rapidly in both groups. We conclude that a one-stage procedure is sufficient in allowing patients with DBH tears in ACL-deficient knees to regain a functional knee to within 5 degrees of full extension.

    View details for Web of Science ID 000079016400013

    View details for PubMedID 10210078