Healthcare Policy and Arthroscopic Rotator Cuff Repair Prices in the United States.

BACKGROUND: Arthroscopic rotator cuff repair (ARCR) is one of the most common orthopedic procedures in the general population. Despite its prevalence, the price of ARCR varies significantly across regions, hospital models, and settings. The purpose of this study was to examine the effect of Geographic Region, Certificate of Need (CON) laws, and Medicaid expansion on ARCR pricing. METHODS: This cross-sectional observational study utilized hospital payer-specific ARCR prices from the Turquoise Health Database using CPT code 29827. These prices are negotiated rates or charges that hospitals establish with various payers, including insurance companies, Medicare, Medicaid, and self-pay patients, for medical services and treatments provided. Outliers below the 10th percentile and above the 90th percentile were excluded. State policies, including CON status and Medicaid expansion, were obtained from public sources, while additional socioeconomic and demographic data were sourced from the US Census. The state's region classification was determined based on one of four Geographic Regions defined by the US Census Bureau. A detailed analysis was also conducted for North Carolina, examining county-level data on urbanization and the Area Deprivation Index (ADI). RESULTS: There were 57,270 ARCR prices from 2,503 hospitals across the United States, with a median interquartile range (IQR) listed price of $6,428.17 (IQR: $2,886.88). States with CON regulations had significantly lower ARCR prices compared to those without ($6,500 vs. $8,000, p<0.0001). Multivariable analysis indicated that hospitals in the Northeast and West Regions listed significantly higher prices for ARCR compared to those in the Midwest Region (p<0.0001). In contrast, hospitals in the South Region listed lower prices for ARCR compared to those in the Midwest Region (p<0.0001). Medicaid expansion was associated with increased ARCR prices (p<0.0001), while CON laws were linked to reduced prices (p< .0001). In North Carolina, ADI and urbanization status did not significantly affect ARCR prices. CONCLUSION: The prices listed for ARCR varied significantly depending on the Geographic Region where hospitals were located. Additionally, CON laws were associated with reduced ARCR prices, while Medicaid expansion correlated with increased prices. These findings highlight the complex interplay between healthcare policy, regulatory frameworks, and socioeconomic factors in determining surgical prices.

How Useful Is TikTok for Patients Searching for Carpal Tunnel Syndrome-Related Treatment Exercises?

Since orthopedic surgery has been slower to acknowledge the rise of social media for distributing medical information, this study aims to evaluate TikTok videos' quality and educational value in relation to carpal tunnel syndrome treatment exercises. TikTok was searched using the hashtags "#carpaltunnelexercises", "#carpaltunnelremedies", "#carpaltunnelrehab", and "#physicaltherapyforcarpaltunnel". The engagement indicators were documented and the video content quality was assessed using the DISCERN, CTEES, JAMA, and GQS grading scales. There were 101 videos included, which accumulated 20,985,730 views. The videos received 1,460,953 likes, 15,723 comments, 243,245 favorites, and 159,923 shares. Healthcare professionals were responsible for 72% of the video uploads, whereas general users contributed 28%. More healthcare professionals' videos were graded as "poor" (79%) compared to general users (21%). General users received slightly more video grades of "very poor" (52%) than healthcare professionals (48%). For the DISCERN grading, the videos by healthcare professionals were significantly better than those by general users in terms of reliability, achieving aims, and relevancy. They were also superior in the overall composition of the health information derived from the total DISCERN score. However, no significant differences were found between the two groups when using the CTEES, JAMA, and GQS grading scales. Overall, despite the emergence of TikTok as a medical information tool, the quality and educational value of the carpal tunnel syndrome exercise videos were poor.

The Effect of Surgeon Volume on Complications Following Total Shoulder Arthroplasty: A Nationwide Assessment.

BACKGROUND: Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 RESULTS: A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001). CONCLUSION: Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

Tendon Transfers in Reverse Total Shoulder Arthroplasty: A Systematic Review.

PURPOSE: The purpose of this study was to evaluate clinical outcomes after tendon transfers in the setting of reverse total shoulder arthroplasty (RTSA). METHODS: PubMed and Embase were searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to find primary clinical studies of any type of tendon transfer in the setting of RTSA. RESULTS: Overall, 17 studies (level of evidence [LOE] I: 1, LOE II: 0, LOE III: 3, LOE IV: 13) met inclusion criteria, with 300 shoulders. Most patients were female (56.7%), with an average age of 68.7 years (range 19 to 89) and a mean follow-up of 46.2 months (range 6 to 174). 11 studies reported outcomes after combined latissimus dorsi and teres major transfer (LDTM) while eight studies reported on latissimus dorsi transfer only (LD). Improvements in commonly reported subjective and functional outcome measures were as follows: external rotation +32° (LDTM) and +30° (LD), flexion +65° (LDTM) and +59° (LD), Visual Analog Score -5.4 (LDTM) and -4.5 (LD), subjective shoulder value +43.8% (LDTM) and +46.3% (LD), and overall Constant score +33.8 (LDTM) and +38.7 (LD). The overall complication rate was 11.3%, including tendon transfer ruptures (0.7%), instability (3.0%), infection (2.0%), and nerve injury (0.3%). The all-cause repeat operation rate was 7.3%, most commonly for arthroplasty revision (5.3%). Subgroup analysis revealed that lateralized implants with tendon transfer resulted in markedly greater improvements in Constant score, flexion, ER1, and ER2 while medialized implants with tendon transfer had markedly greater improvements in Visual Analog Score, subjective shoulder value, and abduction. CONCLUSION: Patients undergoing tendon transfer of either combined LDTM or latissimus dorsi alone in the setting of RTSA have markedly improved subjective and functional outcomes. A moderate incidence of complications (11.3%) was noted in this patient population.

Rotator Cuff Arthropathy: A Comprehensive Review.

Rotator cuff arthropathy is a spectrum of disease states secondary to full-thickness cuff tears classified by rotator cuff insufficiency and degenerative disease within the shoulder joint. Diagnosis can be made through standard physical exam and radiographic films demonstrating varying levels of weakness, along with acetabularization, femoralization, and superior migration of the humeral head. Severity of disease is classified through both the Hamada and Seebauer grading systems, which are used clinically to determine the appropriate treatment algorithm. Treatment exists along the spectrum from conservative therapy with physical therapy to a definitive treatment with total joint replacement. Depending on a patient's progression and other comorbidities, arthroscopic treatments may additionally be used in specific circumstances as joint-sparing techniques. In recent years, reverse total shoulder arthroplasty has produced increasingly favorable outcomes with improvements in pain and function while simultaneously diminishing complication rates, making it generally accepted as standard of care. This disease limits quality of life for a large population of patients and efforts toward optimization of the treatment regimen is critical. This review provides an overview on the diagnostic criteria, classification, pathoanatomic changes, biomechanics, treatment options, outcomes, and complications of rotator cuff arthropathy.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: The purpose of this study was to examine reported MCID and PASS values for PROMs following shoulder instability surgery and assess variability in published values depending on the surgery performed. Secondarily, our aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS usage in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values following Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, Pubmed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English, and studies reporting utilization MCID or PASS for patient reported outcome measures (PROMS) following Latarjet, Bankart, Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using median and range. Categorical variables, including PROMs reported and MCID/PASS methods, were described using percentages. As MCID is a patient-level metric and not a group-level metric, the authors validated that all included studies reported proportions (%) of subjects that met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely utilized outcome threshold which was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (ASES) (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (SANE) (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (WOSI) (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit (SCB) or maximal outcome improvement (MOI). CONCLUSION: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. While MCID has been the most frequently reported metric, there is considerable inter-study variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental, since they allow us to know what is a clinically significant improvement for the patient.

Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations.

Background: The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods: A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results: Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion: The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

Recent Advances in the Design and Application of Shoulder Arthroplasty Implant Systems and Their Impact on Clinical Outcomes: A Comprehensive Review.

Purpose of Review: This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions. Recent Findings: The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA's 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations. Summary: Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.

The impact of political partisanship, certificate of need, Medicaid expansion, and area deprivation index on total shoulder arthroplasty prices in the United States.

BACKGROUND: Recent mandates from the Center for Medicare and Medicaid Services require United States hospitals to disclose health care service pricing. Yet, there's a gap in understanding how state-level factors affect hospital service pricing, like total shoulder arthroplasty (TSA). Comprehending these influences can help policymakers and health care providers manage costs and improve care access for vulnerable populations. The purpose of this study was to examine the effect of state characteristics such as partisan lean, certificate of need (CON) status, and Medicaid expansion on TSA price. METHODS: TSA price data was extracted from the Turquoise Health Database using Current Procedural Terminology code 23472. State partisan lean was determined by evaluating each state during the 2020 election year for its legislature (both senate and house), governor, presidential vote, and Insurance Commissioner Affiliation, categorizing states as either "Republican-leaning" or "Democratic-leaning." CON status, Medicaid expansion, Area Deprivation Index (ADI), and population density information was obtained from publicly available sources. Multivariable regression models were used to assess the relationship between these factors and TSA price. RESULTS: The study included 2068 hospitals nationwide. The median (interquartile range) price of TSA across these hospitals was $12,607 ($9,185). In the multivariable analysis, hospitals in Republican-leaning states were associated with a significantly greater price of +$210 (P = .0151), while Medicaid expansion was also associated with greater price +$1,878 (P < .0001). CON status was associated with a significant reduction in TSA prices of -$2,880 (P < .0001). In North Carolina an ADI >85 was associated with a reduction in price (P = .0045), while urbanization designation did not significantly impact TSA price (P = .8457). CONCLUSION: This cross-sectional observational study found that Republican-leaning states and Medicaid expansion were associated with increased TSA prices, while an ADI >85 and CON laws were associated with reduced TSA prices.

Single-shot interscalene block with liposomal bupivacaine vs. non-liposomal bupivacaine in shoulder arthroplasty.

BACKGROUND: Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB. METHODS: This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use. RESULTS: Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P > .05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P < .05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale-11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P = .57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P = .33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P > .05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P > .05). CONCLUSION: LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.

Identification of ChatGPT-Generated Abstracts Within Shoulder and Elbow Surgery Poses a Challenge for Reviewers.

PURPOSE: To evaluate the extent to which experienced reviewers can accurately discern between artificial intelligence (AI)-generated and original research abstracts published in the field of shoulder and elbow surgery and compare this with the performance of an AI detection tool. METHODS: Twenty-five shoulder- and elbow-related articles published in high-impact journals in 2023 were randomly selected. ChatGPT was prompted with only the abstract title to create an AI-generated version of each abstract. The resulting 50 abstracts were randomly distributed to and evaluated by 8 blinded peer reviewers with at least 5 years of experience. Reviewers were tasked with distinguishing between original and AI-generated text. A Likert scale assessed reviewer confidence for each interpretation, and the primary reason guiding assessment of generated text was collected. AI output detector (0%-100%) and plagiarism (0%-100%) scores were evaluated using GPTZero. RESULTS: Reviewers correctly identified 62% of AI-generated abstracts and misclassified 38% of original abstracts as being AI generated. GPTZero reported a significantly higher probability of AI output among generated abstracts (median, 56%; interquartile range [IQR], 51%-77%) compared with original abstracts (median, 10%; IQR, 4%-37%; P < .01). Generated abstracts scored significantly lower on the plagiarism detector (median, 7%; IQR, 5%-14%) relative to original abstracts (median, 82%; IQR, 72%-92%; P < .01). Correct identification of AI-generated abstracts was predominately attributed to the presence of unrealistic data/values. The primary reason for misidentifying original abstracts as AI was attributed to writing style. CONCLUSIONS: Experienced reviewers faced difficulties in distinguishing between human and AI-generated research content within shoulder and elbow surgery. The presence of unrealistic data facilitated correct identification of AI abstracts, whereas misidentification of original abstracts was often ascribed to writing style. CLINICAL RELEVANCE: With rapidly increasing AI advancements, it is paramount that ethical standards of scientific reporting are upheld. It is therefore helpful to understand the ability of reviewers to identify AI-generated content.

Risk factors for recurrence following arthroscopic Bankart repair: a systematic review.

BACKGROUND: Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. The purpose of this study is to systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair. METHODS: A literature search was performed using the PubMed/MEDLINE databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair. RESULTS: Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a 2-fold recurrence rate of 27.0% (171 of 634) for patients <20 years old compared with 13.3% (197 of 1485) for older patients (P < .001). Seventeen studies completed multivariable analysis, 13 of which were significant (odds ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found odds ratios ranging from 0.7 to 35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29 of 156) risk of recurrence with 2 anchors, compared with 18.1% (89 of 491) with 3 or more anchors (P = .06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant superior labral anterior-posterior tear (0%). CONCLUSION: Younger age, glenoid bone loss, and off-track Hill-Sachs lesions are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

Defining pseudoparalysis and pseudoparesis: a consensus study.

BACKGROUND: The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. METHODS: A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion should be unaffected, the passive range of abduction should not be considered, and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by range of motion rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. CONCLUSION: A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of rotator cuff tears. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Outcomes of arthroscopic stabilization for posterior shoulder instability: a systematic review.

BACKGROUND: Posterior shoulder instability makes up approximately 10% of all shoulder instability cases and its diagnosis and treatment is less well understood. Recently, however, there has been increased recognition of posterior instability and posterior stabilization. The purpose of this study was to systematically review the literature to ascertain the outcomes on arthroscopic stabilization of posterior shoulder instability. METHODS: Two independent reviewers conducted a systematic literature search based on PRISMA guidelines, utilizing the MEDLINE database. Studies were eligible for inclusion if they reported postoperative outcomes for posterior shoulder instability following arthroscopic stabilization. RESULTS: A total of 48 studies met inclusion criteria for review including 2307 shoulders. Majority of patients were male (83.3%), with an average age of 26.1 years and a mean follow-up of 46.8 months. The functional outcome score primarily utilized for postoperative assessment was the American Shoulder and Elbow Surgeons with an average of 84.77. Overall, 90.9% of patients reported being satisfied with their arthroscopic stabilization. Recurrent instability occurred in 7.4% of patients. The total revision rate was 5.2%. 16.6% of patients reported residual pain postoperatively. The rate of return to play was 86.4% with 68.0% of patients returning to play at the same or higher level of play. CONCLUSION: Arthroscopic stabilization of posterior shoulder instability resulted in good outcomes with high patient satisfaction and low rates of recurrent instability, revisions, and residual pain.

Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS: The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE: Level V, expert opinion.

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain. CONCLUSIONS: The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired. LEVEL OF EVIDENCE: Level V, expert opinion.

Clinical outcomes in prospective versus retrospective studies on arthroscopic Bankart repair: a systematic review.

BACKGROUND: The majority of the current literature on arthroscopic Bankart repair is retrospective, and discrepancies exist regarding clinical outcomes including recurrent instability and return to play among studies of different levels of evidence. PURPOSE: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" was used, with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score out of 100. A χ2 test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies. RESULTS: A total of 193 studies were included in the analysis, with 53 prospective studies and 140 retrospective in design. These studies encompassed a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of redislocation in the prospective studies was 8.0% vs. 5.9% in retrospective studies (P < .001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective studies (P = .004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (P = .013). There was no significant difference in terms of overall rate to return to play between prospective and retrospective studies (90% and 91%, respectively; P = .548). The overall rate of non-instability complications in the prospective cohort was 0.27% vs. 0.78% in the retrospective studies (P = .002). CONCLUSIONS: The overall rates of recurrent dislocations-subluxations are higher in prospective studies than retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.

Outcomes and complications of revision reverse shoulder arthroplasty after failed primary anatomic shoulder arthroplasty or hemiarthroplasty: a systematic review.

BACKGROUND: The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, range of motion (ROM), and complication and reoperation rates after revision reverse shoulder arthroplasty (RSA) for a failed primary total shoulder arthroplasty (TSA) or hemiarthroplasty (HA). METHODS: Two independent reviewers performed the literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Studies were included if they reported clinical outcomes for revision RSA for a failed primary TSA or HA. RESULTS: Our review found 23 studies including 1041 shoulders (627 TSA and 414 HA) meeting our inclusion criteria. The majority of patients were female (66.1%), with an average age of 69.0 years (range: 39-93 years) and a mean follow-up of 46.3 months. American Shoulder and Elbow Surgeons and visual analog scale pain scores improved from 32.6 to 61.9 and 6.7 to 2.7, respectively. ROM results include forward flexion, abduction, and external rotation, which improved from 59.4° to 107.7°, 50.7° to 104.4°, and 19.8° to 26.3°, respectively. Only 1 of the 10 studies reporting internal rotation found a statistically significant difference, with the mean internal rotation improving from S1-S3 preoperatively to L4-L5 postoperatively for patients undergoing HA. The overall complication rate and reoperation rate were 23.4% and 12.5%, respectively. The most common complications were glenoid component loosening (6.0%), fracture (periprosthetic, intraoperative, or other scapula fractures) (n = 4.7%), and infection (n = 3.3%). CONCLUSIONS: Revision RSA for a failed primary TSA and HA has been shown to result in excellent functional outcomes and improved ROM, suggesting that patients who have failed TSA or HA may benefit from a revision RSA.

Type V superior labrum anterior to posterior repair: a systematic review.

BACKGROUND: The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following type V superior labrum anterior to posterior (SLAP) repair. METHODS: Two independent reviewers performed a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, utilizing the EMBASE, MEDLINE, and the Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of <.05 was considered to be statistically significant. RESULTS: Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were males (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean American Shoulder and Elbow Surgeons score was 88.3, the mean subjective shoulder value score was 85.5%, and the mean visual analog scale pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in visual analog scale pain scores (mean difference; 0.15, 95% confidence interval, -0.13 to 0.44, I2 = 0%, P = .29) and recurrence rates (risk ratio; 1.38, 95% confidence interval, 0.88-2.15, I2 = 0%, P = .16). CONCLUSION: Arthroscopic repair of type V SLAP tears results in excellent functional outcomes, with high return to play rates in athletes. There are low rates of reoperations and recurrent dislocations. Additionally, in comparison to an isolated Bankart repair, SLAP repair does not increase recurrence rates or postoperative pain.

Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.