Return to work following shoulder arthroplasty: A systematic review.

BACKGROUND: Many patients prioritize the ability to return to work (RTW) after shoulder replacement surgeries such as total shoulder arthroplasty (TSA), reverse TSA (rTSA), and shoulder hemiarthroplasty (HA). Due to satisfactory clinical and functional long-term outcomes, the number of shoulder replacements performed will continue to rise into this next decade. With younger individuals who compose a significant amount of the workforce receiving shoulder replacements, patients will begin to place a higher priority on their ability to RTW following shoulder arthroplasty. AIM: To summarize RTW outcomes following TSA, rTSA, and HA, and analyze the effects of workers' compensation status on RTW rates and ability. METHODS: This systematic review and analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search regarding RTW following shoulder arthroplasty was performed using four databases (PubMed, Scopus, Embase, and Cochrane Library), and the Reference Citation Analysis (https://www.referencecitationanalysis.com/). All studies in English relevant to shoulder arthroplasty and RTW through January 2021 that had a level of evidence I to IV were included. Nonclinical studies, literature reviews, case reports, and those not reporting on RTW after shoulder arthroplasty were excluded. RESULTS: The majority of patients undergoing TSA, rTSA, or HA were able to RTW between one to four months, depending on work demand stratification. While sedentary or light demand jobs generally have higher rates of RTW, moderate or heavy demand jobs tend to have poorer rates of return. The rates of RTW following TSA (71%-93%) were consistently higher than those reported for HA (69%-82%) and rTSA (56%-65%). Furthermore, workers' compensation status negatively influenced clinical outcomes following shoulder arthroplasty. Through a pooled means analysis, we proposed guidelines for the average time to RTW after TSA, rTSA, and HA. For TSA, rTSA, and HA, the average time to RTW regardless of work demand stratification was 1.93 ± 3.74 mo, 2.3 ± 2.4 mo, and 2.29 ± 3.66 mo, respectively. CONCLUSION: The majority of patients are able to RTW following shoulder arthroplasty. Understanding outcomes for rates of RTW following shoulder arthroplasty would assist in managing expectations in clinical practice.

Management of proximal biceps tendon pathology.

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician's knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient's next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Machine learning in orthopaedic surgery.

Artificial intelligence and machine learning in orthopaedic surgery has gained mass interest over the last decade or so. In prior studies, researchers have demonstrated that machine learning in orthopaedics can be used for different applications such as fracture detection, bone tumor diagnosis, detecting hip implant mechanical loosening, and grading osteoarthritis. As time goes on, the utility of artificial intelligence and machine learning algorithms, such as deep learning, continues to grow and expand in orthopaedic surgery. The purpose of this review is to provide an understanding of the concepts of machine learning and a background of current and future orthopaedic applications of machine learning in risk assessment, outcomes assessment, imaging, and basic science fields. In most cases, machine learning has proven to be just as effective, if not more effective, than prior methods such as logistic regression in assessment and prediction. With the help of deep learning algorithms, such as artificial neural networks and convolutional neural networks, artificial intelligence in orthopaedics has been able to improve diagnostic accuracy and speed, flag the most critical and urgent patients for immediate attention, reduce the amount of human error, reduce the strain on medical professionals, and improve care. Because machine learning has shown diagnostic and prognostic uses in orthopaedic surgery, physicians should continue to research these techniques and be trained to use these methods effectively in order to improve orthopaedic treatment.

Development and Evaluation of an Objective Tympanic Membrane Visualization Assessment Technique.

OBJECTIVES: To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs. METHODS: Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients' tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity. RESULTS: Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01). CONCLUSION: The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

Outcomes of Expandable Interbody Devices in Lumbar Fusion: A Systematic Review and Meta-analysis.

STUDY DESIGN: This was a systematic review. OBJECTIVE: The objective of this study was to review radiographic, clinical, and surgical outcomes of expandable interbody device implantation following lumbar fusion. SUMMARY OF BACKGROUND DATA: Few studies have evaluated postsurgical outcomes of expandable implants following lumbar interbody fusion. METHODS: A systematic review was performed to identify studies investigating expandable intervertebral body devices in lumbar fusion. Radiographic parameters, fusion assessments, patient-reported outcomes (PROs), complications, and revision data were recorded. A comparison of expandable and static devices was performed using a meta-analysis. RESULTS: Eleven articles were included. Postoperative improvements for each radiographic parameters for expandable versus static device implantation ranged from: lumbar lordosis, +2.0 to +5.0 degrees (expandable) versus +1.0 to +4.4 degrees (static); segmental lordosis, +1.0 to +5.2 degrees (expandable) versus+1.1 to +2.3 degrees (static); disk height, +0.82 to +4.8 mm (expandable) versus +0.26 to +6.9 mm (static); foraminal height, +0.13 to +2.8 mm (expandable) versus and +0.05 to +3.0 mm (static). Fusion rates ranged from 72.1% at 6 months to 100% at terminal follow-up. Preoperative to final follow-up improvement for the various PROs assessed were: Oswestry Disability Index, -15.4 to -56.3 (expandable) versus -13.6 to -26.3 (static); Visual Analog Scale (VAS) Back, -3.2 to -6.0 (expandable) versus -3.1 to -4.1 (static); and VAS Leg, -2.9 to -7.1 (expandable) -3.0 versus -4.8 (static). Static cages had a reported complication rate ranging from 6.0% to 16.1% and a subsidence rate of 6.0%. Expandable cages had a reported complication rate that ranged from 0.0.% to 10.0% and a subsidence rate of 5.5%-10.0%. A meta-analysis demonstrated a statistically significant difference in the PRO Oswestry Disability Index, but not VAS Back, VAS Leg, or radiographic outcomes (disk height or foraminal height). CONCLUSION: There is no clear evidence for the use of expandable interbody devices over static devices.

The Influence of Conflicts of Interest on Outcomes in the Lumbar Disc Arthroplasty Literature: A Systematic Review.

STUDY DESIGN: A systematic review. OBJECTIVE: The aim of this study was to determine the association between study outcomes and the presence of a conflict of interest (COI) in the lumbar disc arthroplasty (LDA) literature. SUMMARY OF BACKGROUND DATA: Previous studies have evaluated the efficacy of LDA as a surgical alternative to arthrodesis. As investigators may have financial relationships with LDA device companies, it is important to consider the role of COI on study outcomes. METHODS: A systematic review was performed to identify articles reporting clinical outcomes of LDA. Any financial COIs disclosed were recorded and confirmed through Open Payments and ProPublica databases. Study outcomes were graded as favorable, unfavorable, or equivocal. Pearson Chi-squared analysis was used to determine an association between COI and study outcomes. Favorable outcomes were tested for an association with study characteristics using Poisson regression with robust error variance. RESULTS: Fifty-seven articles were included, 30 had a financial COI, while 27 did not. Ninety percent of the conflicted studies disclosed their COI in the article. Studies with United States authors were more likely to be conflicted (P = 0.019). A majority of studies reported favorable outcomes for LDA (n = 39). Conflicted studies were more likely to report favorable outcomes than nonconflicted studies (P = 0.020). Articles with COIs related to consultant fees (P = 0.003), research funding (P = 0.002), and stock ownership (P < 0.001) were more likely to report favorable outcomes. CONCLUSION: This study highlights the importance for authors to accurately report conflicting relationships with industry. As such, orthopedic surgeons should critically evaluate study outcomes with regard to potential conflicts before recommending LDA as a surgical option to their patients. LEVEL OF EVIDENCE: 3.

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

BACKGROUND: To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures. METHODS: A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for. RESULTS: Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts. CONCLUSIONS: Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week. LEVEL OF EVIDENCE: 3.

Utility of a smartphone-enabled otoscope in the instruction of otoscopy and middle ear anatomy.

PURPOSE: To present the utility of a smartphone-enabled otoscope as a teaching adjunct in pre-clinical otoscopy training. METHODS: 60 pre-clinical medical students were randomized into either a control group using a conventional otoscope or an experimental group using a smartphone-enabled otoscope. Participants in each group were trained to use their assigned device and were given time to practice on a colleague's ear. Participants then completed a questionnaire indicating their ability to visualize anatomical landmarks of the middle ear as well as their confidence in performing a middle ear examination using their device. RESULTS: Compared to participants using the conventional otoscope, significantly more students using the smartphone-enabled otoscope identified the umbo (93% versus 63%, P = 0.005), the short process of the malleus (67% versus 33%, P = 0.008), the cone of light (100% versus 70%, P = 0.001), and the pars flaccida (60% versus 33%, P = 0.03). Furthermore, participants who used the smartphone-enabled otoscope reported significantly increased confidence in performing otoscopy compared to those who used a conventional otoscope (4.1 ± 0.7 versus 2.8 ± 0.9, P < 0.001). Finally, participants rated the smartphone-enabled otoscope as an excellent teaching aid for otoscopy training. CONCLUSION: The smartphone-enabled otoscope serves as a valuable teaching tool for pre-clinical otoscopy education. After using the device, pre-clinical students were more confident in performing a middle ear examination and in identifying important anatomical landmarks of the middle ear.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.

BACKGROUND: Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty. METHODS: Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. RESULTS: A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). CONCLUSION: The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Predictive Factors and Duration to Return to Sport After Isolated Meniscectomy.

BACKGROUND: Return to sport (RTS) after meniscectomy is an important metric for young, active patients. However, the impact of the duration from surgery to RTS on clinical outcomes is not fully understood and is not reflected in outcome scores. PURPOSE: To establish when patients RTS after meniscectomy and to determine predictive measures for the ability to return to their preinjury activity. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients undergoing meniscectomy between 2016 and 2017 from a single institution were assessed for inclusion. RTS, type of activity, and level of function upon returning were obtained. The minimal clinically important difference (MCID), substantial clinical benefit, and patient acceptable symptom state (PASS) were calculated for the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) questionnaire using anchor-based and distribution-based approaches. Preoperative knee-specific and generic quality-of-life scores were analyzed to determine their predictive power of RTS. A multivariate logistical analysis was also performed to determine which demographic variables corresponded to RTS. RESULTS: Overall, 94 patients (mean age, 51.0 ± 11.1 years) who underwent meniscectomy participated in sports within 6 months of surgery. Of these patients, 76.6% returned to sport without permanent restrictions at a mean of 8.6 ± 6.9 weeks postoperatively. RTS rates for low-, medium-, and high-intensity activities were 75.0%, 70.0%, and 82.5%, respectively. RTS was associated with achieving the PASS for the KOOS-Physical Function short form (PS), KOOS-Pain, and KOOS-Sports (P = .004, P = .007, and P = .006, respectively) but not for the IKDC questionnaire (P = .3). Achieving the MCID was associated with RTS for the KOOS-Sports, KOOS-Pain, and IKDC questionnaire (P < .001, P = .03, and P = .001, respectively). There was no preoperative or intraoperative variable that was predictive of RTS. Preoperative KOOS-PS scores ≥37.8 (area under the curve = 76.3%) and KOOS-Pain scores ≥51.4 (area under the curve = 72.5%) were predictive of RTS. CONCLUSION: Approximately 77% of patients returned to sport after meniscectomy at a mean of 2 months postoperatively. The level of activity intensity did not significantly alter the rate of RTS. Higher preoperative scores on the KOOS-PS and KOOS-Pain were predictive of RTS. Identifying these factors allows physicians to counsel patients on expected outcomes after meniscectomy.

Factors Associated With Clinically Significant Patient-Reported Outcomes After Primary Arthroscopic Partial Meniscectomy.

PURPOSE: The purpose of this study was to establish minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) after meniscectomy and factors associated with achieving these goals. METHODS: A prospectively maintained institutional registry was retrospectively reviewed for all patients undergoing isolated arthroscopic partial meniscectomy from 2014 through 2017. MCID, SCB, and PASS were calculated for the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores by using the anchor-based methodology and nonparametric receiver operating characteristic curves. Subscores included joint replacement (JR), physical function (PF), symptoms (Sx), pain, activities of daily living (ADL), sport, and quality of life (QOL). RESULTS: A total of 269 patients were analyzed in the study, which reported outcomes between 6 and 7 months after surgery. The average age of our population was 48.9 ± 12.4 years. Twenty patients reported no change, 53 reported minimal improvement, and 137 reported substantial change after surgery; whereas 59 patients reported worse outcomes. One hundred seventy-seven patients were satisfied and 92 were not satisfied with the outcome of surgery. Established MCID/SCB/PASS for the IKDC, KOOS JR, KOOS PF, KOOS Sx, KOOS Pain, KOOS ADL, and KOOS QOL were 10.6/25.3/57.9, 10.7/13.2/68.3, -8.2/-11.3/26.2, 8.9/7.1/71.4, 9.7/22.2/76.4, 11.0/16.9/89.0, 12.5/27.5/55.6, and 15.6/34.4/46.9, respectively. Higher preoperative scores were associated with reduced odds of achieving MCID and SCB but greater odds of achieving PASS for nearly all scores (P < .05). Workers' compensation status, degenerative tears, medial-sided tears, and root tears were associated with reduced odds of achieving 2 or more clinically meaningful outcomes in 2 or more scores (P < .05). CONCLUSIONS: Clinically meaningful outcomes were established by patient self-assessment. Variables associated with achieving these outcomes include preoperative score (positively correlated with MCID/SCB, negatively correlated with PASS); workers' compensation; degenerative, medial-sided tears; and root tears (remaining negatively correlated with MCID/SCB/PASS). These variables should be accordingly measured for confounding in future outcome reporting.

The Impact of Comorbidity Burden on Complications, Length of Stay, and Direct Hospital Costs After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The aim of this study was to determine whether comorbidity as determined by Charlson Comorbidity Index (CCI) is associated with inpatient complication rate, length of stay (LOS), or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). SUMMARY OF BACKGROUND DATA: In the spine literature, comorbidity burden has been associated with an increased risk for complications, prolonged LOS, and greater hospital costs. Few studies have investigated the influence of comorbidity burden on these outcomes in minimally invasive spine surgery populations. METHODS: A prospectively maintained surgical registry of patients undergoing primary, single-level MIS-TLIF was retrospectively reviewed. Patients were stratified by CCI and tested for association with preoperative demographics and perioperative characteristics using Chi-squared analysis or one-way analysis of variance for categorical and continuous variables, respectively. Complication rates, LOS, and direct hospital costs were compared between groups using a one-way analysis of variance. RESULTS: Two hundred ninety-eight patients were included. About 19.8% had a CCI of 0, 41.3% had a CCI of 1 to 2, 27.2% had a CCI of 3 to 4, and 11.7% had a CCI ≥ 5. Elevated CCI was associated with older age, smoking, and insurance status. Elevated CCI was significantly associated with a greater total inpatient complication rate. Regarding LOS and total direct hospital costs, there were no associations identified. However, elevated CCI was associated with greater costs accrued in the intensive care unit, laboratory costs, and cardiology-related costs. CONCLUSION: Greater comorbidity burden as reflected by higher CCI was associated with increased postoperative complication rates following primary, single-level MIS-TLIF. However, this did not lead to prolongations in hospital stay or increased total direct hospital costs. This lack of association may suggest that the limited tissue trauma and operative exposure utilized in minimally invasive approaches may limit the utility of CCI as a predictor of surgical outcomes and costs. LEVEL OF EVIDENCE: 4.