Pilot epinephrine dose-finding study to counter epidural-related blood pressure reduction.

OBJECTIVE: An unwanted side effect associated with epidural analgesia is the reduction in blood pressure (BP) due to the sympathetic blockade. This study evaluated the hemodynamic effects of adding different epinephrine concentrations to epidurally injected local anesthetic solution to counteract sympathectomy. We hypothesized that epinephrine could mitigate the decrease in BP possibly caused by the local anesthetic, specifically decreasing the incidence of hypotension. METHODS: Sixty-six patients were enrolled in a randomized, controlled, quadruple-blinded prospective study into three groups: epidural ropivacaine 0.2% without epinephrine (control) or with 2 µg/mL or 5 µg/mL epinephrine. Our primary outcome was the assessment of differences in hypotension between groups, defined as a >20% decrease in hypotension from baseline to the end of the intraoperative period. RESULTS: Forty-seven patients completed the study, and 19 were withdrawn. Fifteen patients were in the control group, while 16 patients received 0.2% ropivacaine +2 µg/mL epinephrine, and 16 received 0.2% ropivacaine +5 µg/mL epinephrine. The overall rate of hypotension was 21.3% (10/47). There were no statistically significant differences in hypotension rates between the control group (33%) and groups receiving either +2 µg/mL (13%, p=0.165) or +5 µg/mL (19%, p=0.353) of epinephrine. In secondary analyses, respiratory rate showed greater decreases in control groups across the perioperative period compared with treatment groups (p=0.016) CONCLUSION: Adding epinephrine to the epidural local anesthetic did not significantly decrease the rate of hypotension. However, epinephrine mitigated decreases in respiratory rate across the perioperative period. Future studies will focus on increasing group size and higher epinephrine concentrations (10 µg/mL). TRIAL REGISTRATION NUMBER: NCT02722746.

Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty.

BACKGROUND: Satisfaction following shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs. METHODS: A retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004-2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA) with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation [FE], external rotation [ER], and internal rotation [IR] score) whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect. RESULTS: We included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up (mean, 56±32 months). The threshold in postoperative ROM that were associated with no further improvement were: active abduction, 107-113° for PROMs versus 163° for the SAS score; active FE, 149-162° for PROMs versus 176° for the SAS score; active ER, 50-52° for PROMs versus 72° for the SAS score; IR score, 4-5 points for all PROMs versus 6 points for the SAS score. Out of 3,508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs). CONCLUSIONS: Our findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.

Relationship Between Perioperative Regional Anesthesia and the Risk of Missing Acute Compartment Syndrome Following Tibia Fractures.

BACKGROUND: The aim of this study was to determine the incidence of missed compartment syndrome in tibia fractures treated with and without regional anesthesia. METHODS: A retrospective chart review was performed of patients with operative tibial shaft or plateau fractures at a single level-one trauma hospital between January 2015 and April 2022 with a minimum of 3-month follow-up. Patients under 18 years of age, an ipsilateral knee dislocation, known neurologic injury at presentation, or prophylactic fasciotomy were excluded. We defined missed acute compartment syndrome (ACS) as a postinjury motor deficit still present at the 3-month postoperative appointment. For patients that received a peripheral nerve block, we recorded whether a continuous perineural catheter or one-time single-shot injection was performed, and the number of nerves blocked. Incidence rates for ACS were calculated with exact binomial 95% confidence intervals (CIs). Morphine milligram equivalents (MMEs) consumed 24 hours after surgery, use of nerve block, nerve block timing, and type of block were compared using Mann-Whitney and Kruskal-Wallis nonparametric tests. Statistical significance was defined as P < .05. RESULTS: The incidence of compartment syndrome diagnosed and treated during index hospitalization was 2.2% (17/791, 95% CI, 1.3%-3.4%). The incidence of missed ACS was 0.9% (7/791, 95% CI, 0.4%-1.8%). The incidence of missed ACS was not different between those who received nerve block 0.7% (4/610, 95% CI, 0.2%-1.7%), and those who did not (1.7% (3/176, 95% CI, 0.4%-4.8%) P = .19). Within patients receiving a nerve block, all patients with missed ACS (n = 4) received a perineural catheter. Similar missed ACS rates were observed between tibial shaft and plateau fractures. Patients receiving a nerve block had lower MME compared to those who did not receive a nerve block (P < .001). CONCLUSIONS: The results do not provide evidence that perioperative regional anesthesia increases the incidence of missed ACS in patients with operative tibial shaft or plateau injuries. but does decrease postoperative opioid requirements.

Challenging the Concept of Statistical Fragility: Is There Any Value Added?

ABSTRACT: Today, well-designed randomized clinical trials (RCTs) are considered the pinnacle of clinical research, and they inform many practices in orthopaedics. When designing these studies, researchers conduct a power analysis, which allows researchers to strike a balance between (1) enrolling enough patients to detect a clinically important treatment effect (i.e., researchers can be confident that the effect is unlikely due to chance) and (2) cost, time, and risk to patients, which come with enrolling an excessive number of patients. Because researchers will have a desire to conduct resource-efficient RCTs and protect patients from harm, many studies report a p value that is close to the threshold for significance. The concept of the fragility index (FI) was introduced as a simple way to interpret RCT findings, but it does not account for RCT design. The adoption of the FI conflicts with researchers' goals of designing efficient RCTs that conserve resources and limit ineffective or harmful treatments to patients. The use of the FI may reflect many clinicians' lack of familiarity with interpreting p values beyond "significant" or "nonsignificant." Instead of inventing new metrics to convey the same information provided by the p value, greater emphasis should be placed on educating clinicians on how to interpret p values and, more broadly, statistics, when reading scientific studies.

Relationship between pulmonary, cough, and swallowing functions in individuals with amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Evaluations of pulmonary, cough, and swallow function are frequently performed to assess disease progression in amyotrophic lateral sclerosis (ALS), yet the relationship between these functions remains unknown. We therefore aimed to determine relationships between these measures in individuals with ALS. METHODS: One hundred individuals with ALS underwent standardized tests: forced vital capacity (FVC), maximum expiratory/inspiratory pressure (MEP, MIP), voluntary cough peak expiratory flow (PEF), and videofluoroscopic swallow evaluation (VF). Duplicate raters completed independent, blinded ratings using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Descriptives, Spearman's Rho correlations, Kruskal-Wallis analyses, and Pearson's chi-squared tests were completed. RESULTS: Mean and standard deviation across pulmonary and cough measures were FVC: 74.2% predicted (± 22.6), MEP: 91.6 cmH2O (± 46.4), MIP cmH2O: 61.1 (± 28.9), voluntary PEF: 352.7 L/min (± 141.6). DIGEST grades included: 0 (normal swallowing): 31%, 1 (mild dysphagia): 48%, 2 (moderate dysphagia): 10%, 3 (severe dysphagia): 10%, and 4 (life-threatening dysphagia): 1%. Positive correlations were observed: MEP-MIP: r = .76, MIP-PEF: r = .68, MEP-PEF: r = .61, MIP-FVC: r = .60, PEF-FVC: r = .49, and MEP-FVC: r = .46, p < .0001. MEP (p = .009) and PEF (p = .04) differed across DIGEST safety grades. Post hoc analyses revealed significant between group differences in MEP and PEF across DIGEST safety grades 0 versus 1 and grades 0 versus 3, (p < .05). DISCUSSION: In this cohort of individuals with ALS, pulmonary function, and voluntary cough were associated. Expiratory metrics (MEP, PEF) were diminished in individuals with unsafe swallowing, increasing their risk for effectively defending the airway.

Cell Cycle Checkpoints p16 and p21-Strong Predictors of Clinicopathologic Outcomes in High-Grade Osteosarcoma.

PURPOSE: In this study, we used a series of immunohistochemical measurements of 2 cell cycle regulators, p16 and p21, to evaluate their prognostic value, separately and in combination, for the disease outcomes. METHOD: A total of 101 patients with high-grade osteosarcoma were included in this study. Clinicopathologic data were collected, and immunohistochemistry for p16 and p21 was performed and interpreted by 3 independent pathologists. Statistical analysis was performed to assess the strength of each of these markers relative to disease outcome. RESULTS: Our results indicate that more than 90% expression (high) of p16 by immunohistochemistry on the initial biopsy has a strong predictive value for good histologic response to chemotherapy. The patients are also more likely to survive the past 5 years and less likely to develop metastasis than patients with less than 90% p16 (low) expression. The results for p21, on the other hand, show a unique pattern of relationship to the clinicopathologic outcomes of the disease. Patients with less than 1% (low) or more than 50% (high) expression of p21 by immunohistochemistry show a higher chance of metastasis, poor necrotic response to chemotherapy, and an overall decreased survival rate when compared with p21 expression between 1% and 50% (moderate). Our results also showed that the expression of p16 and combined p16 and p21 demonstrates a stronger predictive relationship to 5-year survival than tumor histologic necrosis and p21 alone. DISCUSSION: The results of this study, once proven to be reproducible by a larger number of patients, will be valuable in the initial assessment and risk stratification of the patients for treatment and possibly the clinical trials.

Routine 2-Week Postoperative Radiographs After Geriatric Hip Fracture Fixation: Low Utility and High Cost.

BACKGROUND: Geriatric hip fractures are associated with a large financial burden on both patients and payors, yet minimal data exist regarding postoperative cost optimization and guidelines for delivering high-value care. We assessed the utility and cost of routine radiographs at the first postoperative visit (FPOV) after fixation of geriatric hip fractures. METHODS: We retrospectively evaluated patients with isolated geriatric hip fractures treated with internal fixation between January 2018 and September 2020. Medical records were reviewed to assess whether radiographs at the FPOV changed management. Direct costs of radiographs at the FPOV were estimated using Medicare Fee Schedule data. Indirect costs were estimated by assessing transportation costs. National costs were estimated by extrapolating institutional and Medicare data to the estimated 300,000 to 500,000 annual hip fractures in the United States. RESULTS: Two hundred forty-one patients were included. A majority had intertrochanteric fractures (80%), were injured because of a ground-level fall (94%), and received long intramedullary nails (73%). One patient (1/241, 0.41%) had their postoperative management changed by FPOV radiographs, and that patient had an acute reinjury before their FPOV. Patients discharged home (50/241, 21%) traveled mean 51.3 miles each way, and those discharged to another facility (191/241, 79%) traveled mean 24.1 miles each way. The national estimated direct cost of routine radiographs at the FPOV totaled $10.9 to $18.2 m annually. The national indirect costs are estimated to be $1.2 to $1.9 m annually for patients discharged home and $63.4 to $105.7 m annually for patients discharged to a facility. CONCLUSIONS: Routine radiographs at the FPOV after internal fixation of geriatric hip fractures may not change management and should only be obtained when specifically indicated. Elimination of routine radiographs and conduction of the FPOV virtually by telemedicine could result in national cost savings of estimated $75.5 to $125.8 m annually without compromising quality of care.

Workload Risk Factors for Pitching-Related Injuries in High School Baseball Pitchers.

BACKGROUND: Pitch counts are only one measure of the true workload of baseball pitchers. Newer research indicates that workload measurement and prevention of injury must include additional factors. Thus, current monitoring systems gauging pitcher workload may be considered inadequate. PURPOSE/HYPOTHESIS: The purpose of this study was to develop a novel method to determine workload in baseball pitchers and improve processes for prevention of throwing-related injuries. It was hypothesized that our pitching workload model would better predict throwing-related injuries occurring throughout the baseball season than a standard pitch count model. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This prospective observational study was conducted at an academic medical center and community baseball fields during the 2019 to 2023 seasons. Pitchers aged 13 to 18 years were monitored for pitching-related injuries and workload (which included pitching velocity; intensity, using preseason and in-season velocity as a marker of effort; and pitch counts). RESULTS: A total of 71 pitchers had 313 recorded pitcher outings, 11 pitching-related injuries, and 24,228 pitches thrown. Gameday pitch counts for all pitchers ranged from 19 to 219 (mean, 77.5 ± 41.0). Velocity ranged from 46.8 to 85.7 mph (mean, 71.3 ± 5.8 mph). Intensity ranged from 0.7 to 1.3 (mean, 1.0 ± 0.08). The mean workload was 74.7 ± 40.1 for all pitchers. Risk factors significant for injury included throwing at a higher velocity in game (P = .001), increased intensity (eg, an increase in mean velocity thrown from preseason to in-season; P < .001), and being an older pitcher (P = .014). No differences were found for workload between injured and noninjured pitchers because the analysis was underpowered. CONCLUSION: Our workload model indicated that throwing at a higher velocity, throwing at a higher intensity, and older age were risk factors for injury. Thus, this novel workload model should be considered as a means to identify pitchers who may be at greater risk for injury.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: A cross-sectional survey.

BACKGROUND: Evidence of overlap between endometriosis and chronic pain conditions is emerging; however, little is known about how the pain experience differs based on the presence or absence of endometriosis. OBJECTIVES: In a sample of women reporting chronic pelvic-abdominal pain (CPP), the aim of this study was to characterize differences in pain symptomatology between women with and without endometriosis and to examine the influence of chronic overlapping pain conditions (COPCs) on pain among these two groups. DESIGN: This was a cross-sectional study, based on an online survey. METHODS: Participants (aged 18+ years) completed a survey collecting pain diagnoses and symptoms assessing pelvic pain severity, pain interference, and pain impact. Independent sample t-tests, chi-square, and multiple linear regression models were employed to analyze group differences in pain symptomatology and COPCs. RESULTS: Of the 525 respondents with CPP, 25% (n = 133) reported having endometriosis. Women with endometriosis were younger at the onset of pelvic pain, relative to women without endometriosis (p = 0.04). There were no differences in age, race, ethnicity, or duration of pelvic pain between women with and without endometriosis. Women with endometriosis reported higher pelvic pain severity (+0.8, 95% CI = 0.4-1.1), pain interference (+5.9, 95% CI = 2.4-9.3), and pain impact (+1.9, 95% CI = 0.8-2.9). Endometriosis was associated with a higher number of COPCs (p = 0.003), with 25% (n = 33) of women reporting ⩾3 overlapping pain conditions compared with 12% (n = 45) of those without endometriosis. Women with endometriosis had a higher frequency of fibromyalgia (p < 0.001), chronic fatigue syndrome (p < 0.001), and temporomandibular disorder (p = 0.001). The number of COPCs was associated with higher pain severity, interference, and impact, independently of endometriosis. CONCLUSION: Women with endometriosis experienced higher levels of pain-related burden and COPCs compared with those without endometriosis. Pain intensity, interference, and impact increased with a higher number of pain conditions regardless of endometriosis presence.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic­abdominal pain: A cross-sectional surveyThe presence of endometriosis was associated with a higher number of chronic overlapping pain conditions (COPCs) and greater pain symptomatology, while a greater number of COPCs corresponded to increased pain burden among women with and without endometriosis. These findings underscore the need for a more comprehensive assessment of endometriosis that addresses the full experience of the disease, including its comorbidities. A greater characterization and measurement of COPCs has the potential to facilitate the development of tailored interventions for individuals with pain comorbidities, thereby contributing to improved clinical care strategies for endometriosis-related pain.

Individual Patient Data Meta-Analysis of Dynamic Cerebral Autoregulation and Functional Outcome After Ischemic Stroke.

BACKGROUND: The relationship between dynamic cerebral autoregulation (dCA) and functional outcome after acute ischemic stroke (AIS) is unclear. Previous studies are limited by small sample sizes and heterogeneity. METHODS: We performed a 1-stage individual patient data meta-analysis to investigate associations between dCA and functional outcome after AIS. Participating centers were identified through a systematic search of the literature and direct invitation. We included centers with dCA data within 1 year of AIS in adults aged over 18 years, excluding intracerebral or subarachnoid hemorrhage. Data were obtained on phase, gain, coherence, and autoregulation index derived from transfer function analysis at low-frequency and very low-frequency bands. Cerebral blood velocity, arterial pressure, end-tidal carbon dioxide, heart rate, stroke severity and sub-type, and comorbidities were collected where available. Data were grouped into 4 time points after AIS: <24 hours, 24 to 72 hours, 4 to 7 days, and >3 months. The modified Rankin Scale assessed functional outcome at 3 months. Modified Rankin Scale was analyzed as both dichotomized (0 to 2 versus 3 to 6) and ordinal (modified Rankin Scale scores, 0-6) outcomes. Univariable and multivariable analyses were conducted to identify significant relationships between dCA parameters, comorbidities, and outcomes, for each time point using generalized linear (dichotomized outcome), or cumulative link (ordinal outcome) mixed models. The participating center was modeled as a random intercept to generate odds ratios with 95% CIs. RESULTS: The sample included 384 individuals (35% women) from 7 centers, aged 66.3±13.7 years, with predominantly nonlacunar stroke (n=348, 69%). In the affected hemisphere, higher phase at very low-frequency predicted better outcome (dichotomized modified Rankin Scale) at <24 (crude odds ratios, 2.17 [95% CI, 1.47-3.19]; P<0.001) hours, 24-72 (crude odds ratios, 1.95 [95% CI, 1.21-3.13]; P=0.006) hours, and phase at low-frequency predicted outcome at 3 (crude odds ratios, 3.03 [95% CI, 1.10-8.33]; P=0.032) months. These results remained after covariate adjustment. CONCLUSIONS: Greater transfer function analysis-derived phase was associated with improved functional outcome at 3 months after AIS. dCA parameters in the early phase of AIS may help to predict functional outcome.

Physical activity positively impacts disability outcomes during transition from midlife to early older age irrespective of body mass index.

We examined the effects of physical activity (PA) and body mass index (BMI) longitudinal patterns (trajectories) on subjective measures of mobility, function, and disability in adults and assessed whether effects of PA trajectories on function varied due to BMI. Group-based trajectory analyses were used to determine patterns of change in PA and BMI using data from the Health and Retirement Study 1931-1941 birth cohort (n = 10,507). Physical function was assessed by Mobility Limitations (0-5 scale) and Large Muscle Function (0-4 scale) Indexes, as well as with score for activities of daily living (ADLs) and instrumental activities of daily living (IADLs), with higher scores being worse. Our analyses estimated four distinct PA trajectories: decreasing, (2) fluctuating, (3) stable high, and (4) emergent (previously low/sedentary with increased PA over the study period). Worse mobility limitations, large muscle function, ADLs, and IADLs were associated with Decreasing and Fluctuating PA groups. Better outcomes were associated with Emergent and Stable High PA groups. The five BMI trajectories were stable normal/overweight, modest decreasing, fluctuating, steep decreasing, and increasing. No significant interaction existed between PA and BMI trajectories for Mobility Limitations (P= 0.577), Large Muscle Function (P= 0.511), ADLs (P= 0.600), and IADLs (P= 0.152). These findings may empower clinicians to promote messages to midlifers that meaningful changes in PA can improve function in older age.

Real-World Experience on Why Research Flatlines: A Review of Trials From the Coordinator's Perspective.

INTRODUCTION: Investigator-initiated research trial failure is a national concern that hinders the dissemination of information while wasting resources, time, and funding. The goal of this analysis was to provide an objective review of points to consider increasing an investigator's chances of success. METHODS: The included trials were divided into two groups based on whether they were successful or unsuccessful in meeting enrollment goals. Common issues were noted for each trial to identify prevalent issues and compare their quantity within each group. RESULTS: Unsuccessful trials averaged twice as many issues as trials in the successful group. The most common problems identified in unsuccessful studies involved study planning, whereas the most common problems identified in successful studies revolved around study staff. CONCLUSIONS: There is no single definitive indicator for trial failure; however, awareness of these issues in a trial's planning phase can help prevent their occurrence and aid in overall completion and publication.

Hypertension and urologic chronic pelvic pain syndrome: An analysis of MAPP-I data.

BACKGROUND: Urologic chronic pelvic pain syndrome (UCPPS), which includes interstitial cystitis/bladder pain syndrome (IC/BPS) and chronic prostatitis (CP/CPPS), is associated with increased voiding frequency, nocturia, and chronic pelvic pain. The cause of these diseases is unknown and likely involves many different mechanisms. Dysregulated renin-angiotensin-aldosterone-system (RAAS) signaling is a potential pathologic mechanism for IC/BPS and CP/CPPS. Many angiotensin receptor downstream signaling factors, including oxidative stress, fibrosis, mast cell recruitment, and increased inflammatory mediators, are present in the bladders of IC/BPS patients and prostates of CP/CPPS patients. Therefore, we aimed to test the hypothesis that UCPPS patients have dysregulated angiotensin signaling, resulting in increased hypertension compared to controls. Secondly, we evaluated symptom severity in patients with and without hypertension and antihypertensive medication use. METHODS: Data from UCPPS patients (n = 424), fibromyalgia or irritable bowel syndrome (positive controls, n = 200), and healthy controls (n = 415) were obtained from the NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic Pain I (MAPP-I). Diagnosis of hypertension, current antihypertensive medications, pain severity, and urinary symptom severity were analyzed using chi-square test and t-test. RESULTS: The combination of diagnosis and antihypertensive medications use was highest in the UCPPS group (n = 74, 18%), followed by positive (n = 34, 17%) and healthy controls (n = 48, 12%, p = 0.04). There were no differences in symptom severity based on hypertension in UCPPS and CP/CPPS; however, IC/BPS had worse ICSI (p = 0.031), AUA-SI (p = 0.04), and BPI pain severity (0.02). Patients (n = 7) with a hypertension diagnosis not on antihypertensive medications reported the greatest severity of pain and urinary symptoms. CONCLUSION: This pattern of findings suggests that there may be a relationship between hypertension and UCPPS. Treating hypertension among these patients may result in reduced pain and symptom severity. Further investigation on the relationship between hypertension, antihypertensive medication use, and UCPPS and the role of angiotensin signaling in UCPPS conditions is needed.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study.

BACKGROUND: Anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) are well-established treatments for patients with primary osteoarthritis and an intact cuff. However, it is unclear whether aTSA or rTSA provides superior outcomes in patients with preoperative external rotation (ER) weakness. METHODS: A retrospective review of a prospectively collected shoulder arthroplasty database was performed between 2007 and 2020. Patients were excluded for preoperative diagnoses of nerve injury, infection, tumor, or fracture. The analysis included 333 aTSAs and 155 rTSAs performed for primary cuff-intact osteoarthritis with 2-year minimum follow-up. Defining preoperative ER weakness as strength <3.3 kilograms (7.2 pounds), 3 cohorts were created and matched: (1) weak aTSAs (n = 74) vs. normal aTSAs (n = 74), (2) weak rTSAs (n = 38) vs. normal rTSAs (n = 38), and (3) weak rTSAs (n = 60) vs. weak aTSAs (n = 60). We compared range of motion, outcome scores, strength, complications, and revision rates at the latest follow-up. RESULTS: Despite weak aTSAs having poorer preoperative strength in forward elevation and ER (P < .001), neither of these deficits persisted postoperatively compared with the normal cohort. Likewise, weak rTSAs had poorer preoperative strength in forward elevation and ER, overhead motion, and Constant, Shoulder Pain and Disability Index, and University of California, Los Angeles scores (P < .029). However, no statistically significant differences were found between preoperatively weak and normal rTSAs. When comparing weak aTSA vs. weak rTSA, no differences were found in preoperative and postoperative outcomes, proportion of patients achieving the minimal clinically important difference and substantial clinical benefit, and complication and rate of revision surgery. CONCLUSIONS: In preoperatively weak patients with cuff-intact primary osteoarthritis, aTSA leads to similar postoperative strength, range of motion, and outcome scores compared with patients with normal preoperative strength, indicating that preoperative weakness does not preclude aTSA use. Furthermore, patients who were preoperatively weak in ER demonstrated improved postoperative rotational motion after undergoing aTSA and rTSA, with both groups achieving the minimal clinically important difference and substantial clinical benefit at similar rates.

Does hydrogen peroxide application to the dermis following surgical incision affect Cutibacterium acnes cultures in total shoulder arthroplasty in male patients? A randomized controlled trial.

BACKGROUND: Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H2O2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H2O2 directly to the dermis following skin incision would further decrease deep culture positivity rates. METHODS: We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H2O2, ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H2O2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors. RESULTS: Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P = .600) and final (61% vs. 50%, P > .999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P = .130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P = .048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P = .023). There were no wound complications in either cohort. CONCLUSIONS: An additional H2O2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H2O2 to decrease C acnes contamination.

Anatomic versus reverse total shoulder arthroplasty outcomes after prior contralateral anatomic total shoulder arthroplasty in patients with bilateral primary osteoarthritis with an intact rotator cuff.

PURPOSE: We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population. METHODS: A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups. CONCLUSION: Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND: Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. METHODS: We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. RESULTS: Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA. CONCLUSIONS: Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation.

Aims: Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. Methods: This was a retrospective review of a single institution's prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates. Results: Compared with non-stiff aTSAs, stiff aTSAs had poorer passive FE and active external rotation (ER), whereas there were no significant postoperative differences between stiff rTSAs and non-stiff rTSAs. There were no significant differences in preoperative function when comparing stiff aTSAs with stiff rTSAs. However, stiff rTSAs had significantly greater postoperative active and passive FE (p = 0.001 and 0.004, respectively), and active abduction (p = 0.001) compared with stiff aTSAs. The outcome scores were significantly more favourable in stiff rTSAs for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, and the Constant score, compared with stiff aTSAs. When comparing the proportion of stiff aTSAs versus stiff rTSAs that exceeded the minimal clinically important difference and substantial clinical benefit, stiff rTSAs achieved both at greater rates for all measurements except active ER. The complication rate did not significantly differ between stiff aTSAs and stiff rTSAs, but there was a significantly higher rate of revision surgery in stiff aTSAs (p = 0.007). Conclusion: Postoperative overhead ROM, outcome scores, and rates of revision surgery favour the use of a rTSA rather than aTSA in patients with glenohumeral OA, an intact rotator cuff and limited FE, with similar rotational ROM in these two groups.

Early outcomes after first reverse total shoulder arthroplasty better prognosticate contralateral success compared with early outcomes after anatomic total shoulder arthroplasty.

BACKGROUND: The ideal timing between bilateral total shoulder arthroplasty (TSA) is unclear. The purpose of this study is to determine whether early outcomes after first TSA can be used to predict clinical outcomes after TSA of the contralateral shoulder and to evaluate the ideal time after TSA to perform the contralateral shoulder. METHODS: A single-institution prospectively collected shoulder arthroplasty database was reviewed. Patients who underwent bilateral primary anatomic or reverse TSA (aTSA + rTSA) without an indication of fracture, tumor, or infection were identified. Included patients had minimum 2-year follow-up on their second TSA and postoperative follow-up after their first TSA at 3 months, 6 months, 1 year, or 2 years. Our primary outcome was whether outcome scores and motion at 3-month, 6-month, 1-year, and 2-year follow-up after first TSA predicted clinical success after second TSA at final follow-up, defined as achieving the patient acceptable symptomatic state (PASS = the highest level of symptoms beyond which patients consider themselves well). Outcomes included the American Shoulder and Elbow Surgeons and Constant scores, abduction, forward elevation, and external/internal-rotation. Multivariable logistic regression determined whether postoperative outcomes after first TSA were predictive of achieving the PASS after second TSA independent of age, sex, and body mass index. Receiver operating characteristic analysis determined cutoffs of postoperative outcomes after first TSA at each time point that best predicted achieving the prosthesis-specific PASS after second TSA. RESULTS: One hundred thirty-four patients were included in the final analysis (110 aTSA and 158 rTSA). Range of motion and outcome scores at late (1- or 2-year) follow-up after first aTSA were more predictive of achieving the second TSA PASS compared with early (3- or 6-month) outcomes. In contrast, outcomes after early and late follow-up after first rTSA were similarly predictive of achieving the second TSA PASS. Specifically, the Constant score threshold at 2 years after first aTSA (79.4; area under the curve [AUC] = 0.804) better differentiated achieving the second TSA PASS vs. the 6-month threshold (72.0; AUC = 0.600). In contrast, the Constant score threshold at 2 years after first rTSA (76.4; AUC = 0.703) was similarly discriminant of achieving the second TSA PASS compared with the 6-month threshold (65.8; AUC = 0.711). CONCLUSIONS: Patients with good outcomes after first rTSA can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. In contrast, success after first aTSA does not reliably predict contralateral success until ≥1 year.