Measure what matters: Single Assessment Numeric Evaluation (SANE) score as the critical measure for shoulder outcomes.

BACKGROUND: Implementation of a system anchored in patient outcomes is challenged to gain widespread adoption required to demonstrate the value of care provided for shoulder conditions. This is in large part because of the administrative burden created by current tools and clinical implementation barriers that limit practical use and therefore leave most clinicians, administrators, payers, and patients without a measure of what matters most: Are patients improving? Thus, we must ask ourselves, How do we accurately and efficiently measure and report quality of care in a simple, reliable, and easily communicated manner? We propose that the Single Assessment Numeric Evaluation (SANE) score is the best solution to measure patient improvement and can be used universally for all shoulder conditions. The measure is simple, valid, reliable, and sensitive to change and has the lowest implementation barrier compared with all other outcome measures. METHODS: We synthesized the available literature (11 studies) that demonstrates strong psychometrics comparable to legacy measures across >4000 patients with a wide range of shoulder conditions. RESULTS: SANE scores range from 40% to 60% at baseline for most patients before treatment and range from 75% to 85% at 1 year after therapy depending on the condition, similar to legacy scores such as the American Shoulder and Elbow Surgeons score. Additionally, the SANE score shows similar baseline and post-care measures across conditions that can be used to guide clinical care. This finding shows that the observed baseline and improvement scores can provide valuable patient assessment and can be used in aggregate for quality improvement and other value-based purposes. CONCLUSION: We strongly recommend the SANE score as the primary patient outcome measure for patients with all shoulder conditions, given the value of measuring every patient's progress and growing pressure to quantify patient outcomes.

ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures.

BACKGROUND: The ability to do comparative effectiveness research (CER) for proximal humerus fractures (PHF) using data in electronic health record (EHR) systems and administrative claims databases was enhanced by the 10th revision of the International Classification of Diseases (ICD-10), which expanded the diagnosis codes for PHF to describe fracture complexity including displacement and the number of fracture parts. However, these expanded codes only enhance secondary use of data for research if the codes selected and recorded correctly reflect the fracture complexity. The objective of this project was to assess the accuracy of ICD-10 diagnosis codes documented during routine clinical practice for secondary use of EHR data. METHODS: A sample of patients with PHFs treated by orthopedic providers across a large, regional health care system between January 1, 2016, and December 31, 2018, were retrospectively identified from the EHR. Four fellowship-trained orthopedic surgeons reviewed patient radiographs and recorded the Neer Classification characteristics of displacement, number of parts, and fracture location(s). The fracture characteristics were then reviewed by a trained coder, and the most clinically appropriate ICD-10 diagnosis code based on the number of fracture parts was assigned. We assessed congruence between ICD-10 codes documented in the EHR and radiograph-validated codes, and assessed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EHR-documented ICD-10 codes. RESULTS: There were 761 patients with unilateral, closed PHF who met study inclusion criteria. On average, patients were 67 years of age and 77% were female. Based on radiograph review, 37% were 1-part fractures, 42% were 2-part, 11% were 3-part, and 10% were 4-part fractures. Of the EHR diagnosis codes recorded during clinical practice, 59% were "unspecified" fracture diagnosis codes that did not identify the number of fracture parts. Examination of fracture codes revealed PPV was highest for 1-part (PPV = 0.66, 95% confidence interval [CI] 0.60-0.72) and 4-part fractures (PPV = 0.67, 95% CI 0.13-1.00). CONCLUSIONS: Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for PHF. Conclusions drawn from population studies or large databases using ICD-10 codes for PHF classification should be interpreted within this limitation. Future studies are warranted to improve diagnostic coding to support large observational studies using EHR and administrative claims data.

Judicious use of corticosteroid injections prior to shoulder arthroplasty does not compromise outcomes at a minimum of 2 years following surgery.

BACKGROUND: The use of total shoulder arthroplasty is continuing to rise with its expanding indications. For patients with chronic conditions, such as glenohumeral arthritis and rotator cuff arthropathy, nonoperative treatment is typically done prior to arthroplasty and often includes corticosteroid injections (CSIs). Recent studies in the shoulder arthroplasty literature as well as applied from the hip and knee literature have focused on the risk of periprosthetic infection. Literature is lacking as to whether the judicious use of corticosteroids in the year prior to arthroplasty influences patient-reported outcomes (PROs). The purpose of this study was to determine if preoperative CSIs prior to shoulder arthroplasty affected 2-year PROs. METHODS: Retrospective review of anatomic and reverse total shoulder arthroplasty (RSA) patients (n = 230) was performed at a single institution including multiple surgeons. Patients were included if they had preoperative and a minimum of 2-year postoperative PROs, including: American Shoulder and Elbow Surgeons (ASES), visual analog scale, Single Assessment Numeric Evaluation, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score. Patients were included in the injection group if they had received an injection, either glenohumeral or subacromial, within 12 months prior to arthroplasty (inject = 134). Subgroup analysis included anatomic (total shoulder arthroplasty [TSA] = 92) and RSA (RSA = 138) as well as those with no injection within 12 months prior to surgery. An analysis of variance was used to compare outcomes between patients who received an injection and those who did not prior to TSA and RSA. RESULTS: There were 230 patients included with 134 patients in the injection group and 96 in the no injection group. Patients who received an injection in the year prior to arthroplasty displayed a significantly higher ASES (82 [16.23 standard deviation] vs. 76 [19.43 standard deviation], P < .01) and Single Assessment Numeric Evaluation (70 [24.49 standard deviation] vs. 63 [29.22 standard deviation], P < .01) scores vs. those who had not received injection. There was no difference when comparing preoperative injection vs. no injection in patients undergoing TSA. Those patients undergoing RSA displayed significantly higher ASES scores (P < .01). There were no significant differences in visual analog scale, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score among any analysis (P > .05), and the minimal clinically important difference in ASES was not different between groups (P.09). CONCLUSION: CSIs within 12 months prior to anatomic and RSA do not compromise PROs during a minimum of 2-year follow-up. Although more complications occurred in the injection group, it did not reach statistical significance and warrants further study in a larger population.

No clinical difference in outcomes between inlay and onlay arthroscopic biceps tenodesis techniques during rotator cuff repair.

BACKGROUND: Both inlay and onlay arthroscopic biceps tenodesis (ABT) are common procedures performed during rotator cuff repair. The inlay method involves creating a bone socket in the bicipital groove to secure the long head of the biceps tendon using an interference screw. The onlay method utilizes a suture anchor to secure the long head of the biceps tendon on the surface of the bicipital groove. Little is known on the long-term differences in patient-reported outcomes between these 2 techniques. The primary purpose of this study was to compare patient-reported outcomes of inlay vs. onlay ABT with a minimum follow-up of 2 years. Secondary aims were to evaluate the impact of rotator cuff tear size on outcomes and compare rates of complications between the 2 techniques. METHODS: A retrospective chart review was performed to identify patients who had an ABT during a full-thickness rotator cuff repair. Any symptom specific to the biceps were noted, including pain and cramping, Popeye deformity, or revision surgery. Complication rates were compared between groups. The visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Veteran's RAND-12 score (VR-12) scores were compared at 2 years. The impact of rotator cuff tear size was analyzed by categorizing into small/medium or large/massive based on operative reports and arthroscopic images. RESULTS: There were 165 patients identified (106 in the inlay group and 59 in the onlay group). No revision surgeries were performed secondary to the biceps tendon in either group. Eleven patients (10%) in the inlay group complained of biceps pain or cramping compared to 2 patients (3%) in the onlay group (P = .11). One Popeye deformity was noted in each group (P = .67). No significant differences were found between groups for visual analog scale (P = .41), ASES functional (P = .61), ASES index (P = .91), Single Assessment Numeric Evaluation (P = .09), VR-12 Physical Component Score (P = .77), or VR-12 Mental Component Score (P = .09). Rotator cuff tear size within the groups also did not demonstrate statistical significance. CONCLUSION: No clinical differences or complications were found at minimum 2-year follow-up between inlay and onlay ABT in patients undergoing rotator cuff repair when controlling for tear size. The clinical relevance suggests either technique is effective and can be based on surgeon preference.

Impact of Prolonged Sport Stoppage on Knee Injuries in High School Athletes: An Ecological Study.

CONTEXT: In March 2020, public health concerns resulted in school closure throughout the United States. The prolonged sport cessation may affect knee injury risk in high school athletes. The purpose of this study was to describe and compare risk of knee injuries in high school athletes during 2019-2020 and 2020-2021 academic years, and stratify by gender, severity, mechanism of injury, injury type, and knee anatomic region. DESIGN: Historical-prospective cohort study. METHODS: This historical-prospective cohort study included 176 schools in 6 states matched by sport participation in control and COVID years from July 1, 2019 to June 30, 2021. Injury rates per 1000 athletes per year were calculated with 95% confidence intervals. A negative binomial regression was performed to assess potential differences in knee injuries between academic years. RESULTS: 94,847 and 72,521 high school athletes participated in the 2019-2020 (19-20) and 2020-2021 (20-21) seasons. Knee injury risk was higher in the 20-21 season (19-20: 28.89% [27.82-29.96]; 20-21: 33.82% [32.50-35.14]). Risk increased for male athletes from 2019-2020 to 2020-2021 (19-20: 29.42% [28.01-30.83]; 20-21: 40.32% [38.89-41.75]). Female knee injury risk was similar between years (19-20: 25.78% [24.29-27.27]; 20-21: 26.03% [24.31-27.75]). Knee injuries increased by a ratio of 1.2 ([95% CI, 1.1-1.3], P < .001) during 2020-2021. CONCLUSIONS: Knee injury risk and relative risk increased among males in 2020-2021. Results indicate changes in knee injury risk following return from COVID shelter in place among high school athletes and implicate potential negative downstream effects of interrupted sports training and participation on high school injury risk.

Higher rates of concussion following COVID-19 infection in high school athletes.

OBJECTIVE: To compare concussion rates (CRs) over one academic year in high school athletes with and without a COVID-19 infection prior to concussion. METHODS: Illness and concussion were prospectively reported for male and female high school athletes across six states over one academic year in the Players Health Rehab surveillance system. Concussion was truncated to 60 days following recovery and return to sport from COVID-19. CRs were estimated per 1000 athletes per academic year and stratified by those who tested positive for COVID-19 infection (with COVID-19) and those who did not (no COVID-19). Poisson regression analyses estimated rate ratio (RR) of concussion controlling for state, gender and an offset of the log athlete participation (with COVID-19 and no COVID-19). RESULTS: Of 72 522 athletes, 430 COVID-19 infections and 1273 concussions were reported. The CR was greater in athletes who reported COVID-19 (CR=74.4/1000 athletes/year, 95% CI 49.6 to 99.3) compared with those who did not (CR=17.2, 95% CI 16.3 to 18.2). Athletes with recent COVID-19 had a threefold higher rate of concussion (RR=3.1, 95% CI 2.0 to 4.7). CONCLUSION: Athletes returning from COVID-19 had higher CRs than those who did not experience COVID-19. This may be related to ongoing COVID-19 sequelae or deconditioning related to reduced training and competition load during the illness and when returning to sport. Further research is needed to understand the association of recent COVID-19 infection and concussion in order to inform preventive strategies.

Arm injury in youth baseball players: a 10-year cohort study.

BACKGROUND: Arm injuries are commonly encountered in baseball as young athletes play into adulthood. The purpose of this study was to examine the incidence of arm injury and risk for surgery in adolescent baseball players followed over a 10-year period from scholastic, age-group, and travel baseball leagues through their highest level of competition. METHODS: A prospective study was conducted enrolling middle and high school baseball players in 2010-2012, then followed for 10 years or until retirement from competitive baseball. Players were included if fully participating in team activities at the time of preseason study enrollment. Players with prior arm (shoulder or elbow) surgery or those diagnosed with time loss arm injury within the past year were excluded. Only shoulder and elbow overuse problems resulting in time-loss from sport and medical attention from a sports medicine physician or orthopedic surgeon were documented as injuries in this study. Musculoskeletal overuse injuries were classified based on the orchard injury classification system. Incidence proportion and risk ratio (RR) and 95% confidence intervals (CIs) for initial injury and injuries requiring surgery were calculated. RESULTS: A total of 261 pitchers (age: 14.2 ± 2.6 years; follow-up: 4.2 ± 2.7 years) were enrolled. Twenty percent of the cohort was followed for ≥7 years. The overall injury incidence was 25.6/100 athletes (95% CI 21-31) with a cumulative surgical incidence of 5.4/100 athletes (95% CI 3.2-8.8). The risk of experiencing shoulder injury (n = 25) and elbow injury (n = 38) were similar (n = 38) (RR 0.7, 95% CI 0.4-1.1). The athletes also presented with a similar frequency of requiring surgery regardless of the injured body part. However, the risk of surgery in those playing beyond the high school level was 4.3 times greater (95% CI 1.2-15.0) than those only playing high school. CONCLUSION: This is the first study to follow a large cohort of youth baseball players as they progress, showing a relatively high arm injury incidence. Shoulder and elbow injury incidence was similar but surgical risk increased playing beyond high school, specifically for the elbow. The high injury frequency and burden of care required by young baseball players as reported in this study is concerning, and strategies to reduce injury should be investigated.

Unanticipated costs associated with interscalene nerve catheters for shoulder surgery.

BACKGROUND: Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of ongoing care or complications. Pulmonary complications can lead to unexpected admissions and emergency department visits. The purpose of the study was to identify unplanned hospital admissions or emergency department visits related to regional anesthesia after shoulder surgery and determine the additional associated costs. METHODS: A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single, large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients, whereas 160 patients had a single-shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at 1, 2, 7, and 14 days following surgery. All emergency department visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care. RESULTS: Of the 1728 patients who had CIB, 10 patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency department visit or readmission. The average age of the 10 patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days, with 1 patient requiring admission to the intensive care unit. The average cost of admission to the hospital or visit to the emergency department was $6849 (range, $1988-$19,483). These costs were primarily related to chest radiographs and electrocardiogram (9/10), chest computed tomography (CT) with contrast (3/10), and head CT (2/10). CONCLUSION: Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency department workup may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.

Improving Clinical Utility of Real-World Prediction Models: Updating Through Recalibration.

ABSTRACT: Bullock, GS, Shanley, E, Thigpen, CA, Arden, NK, Noonan, TK, Kissenberth, MJ, Wyland, DJ, and Collins, GS. Improving clinical utility of real-world prediction models: updating through recalibration. J Strength Cond Res 37(5): 1057-1063, 2023-Prediction models can aid clinicians in identifying at-risk athletes. However, sport and clinical practice patterns continue to change, causing predictive drift and potential suboptimal prediction model performance. Thus, there is a need to temporally recalibrate previously developed baseball arm injury models. The purpose of this study was to perform temporal recalibration on a previously developed injury prediction model and assess model performance in professional baseball pitchers. An arm injury prediction model was developed on data from a prospective cohort from 2009 to 2019 on minor league pitchers. Data for the 2015-2019 seasons were used for temporal recalibration and model performance assessment. Temporal recalibration constituted intercept-only and full model redevelopment. Model performance was investigated by assessing Nagelkerke's R-square, calibration in the large, calibration, and discrimination. Decision curves compared the original model, temporal recalibrated model, and current best evidence-based practice. One hundred seventy-eight pitchers participated in the 2015-2019 seasons with 1.63 arm injuries per 1,000 athlete exposures. The temporal recalibrated intercept model demonstrated the best discrimination (0.81 [95% confidence interval [CI]: 0.73, 0.88]) and R-square (0.32) compared with original model (0.74 [95% CI: 0.69, 0.80]; R-square: 0.32) and the redeveloped model (0.80 [95% CI: 0.73, 0.87]; R-square: 0.30). The temporal recalibrated intercept model demonstrated an improved net benefit of 0.34 compared with current best evidence-based practice. The temporal recalibrated intercept model demonstrated the best model performance and clinical utility. Updating prediction models can account for changes in sport training over time and improve professional baseball arm injury outcomes.

Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture.

BACKGROUND: Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators. METHODS: IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties. RESULTS: IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery. CONCLUSIONS: IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data.

Initial kinematic chain injuries increase hazard of subsequent arm injuries in professional baseball pitchers.

BACKGROUND: Currently, there are few studies that have evaluated the relationship between a lower extremity or trunk injury (kinematic chain) and subsequent arm injury. The purpose of this study was (1) to investigate the relationship between initial kinematic chain (lower extremity or trunk) injury and subsequent arm injury; and (2) to investigate the relationship between initial shoulder or elbow injury and subsequent arm injury. METHODS: A 7-year prospective injury risk study was conducted with Minor League Baseball pitchers. Pitches, pitching appearances, athlete exposures (AEs), and arm injuries (≥1-day time loss) were documented throughout the season. Cox survival analyses with 95% confidence intervals (95% CIs) were performed. Confounders controlled for included age, body mass index, arm dominance, pitching role, previous arm injury, number of pitching appearances, and seasonal pitch load. RESULTS: A total of 297 pitchers participated (total player days = 85,270). Arm injury incidence was 11.4 arm injuries/10,000 AEs, and kinematic chain incidence was 5.2 injuries/10,000 AEs. Pitchers who sustained a kinematic chain injury demonstrated a greater hazard (2.6 [95% CI: 1.2, 5.6], P = .019) of sustaining an arm injury. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard (9.3 [95% CI: 1.1, 83], P = .047) of sustaining a subsequent shoulder or elbow injury compared with pitchers who sustained an initial elbow injury. CONCLUSIONS: Pitchers who sustained an initial lower extremity or trunk injury demonstrated an increased subsequent arm injury hazard compared with pitchers who did not. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard of sustaining a subsequent arm injury compared with pitchers who sustained an initial elbow injury. However, this secondary analysis should be interpreted with caution. Clinicians should monitor risk with workload accumulation, which may be related to pitching compensatory strategies in a fatigued state. Pitchers who sustain a shoulder injury should be evaluated and perform both shoulder and elbow rehabilitation strategies before return to sport.

Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial.

BACKGROUND: Treating high-grade (grade 2 and 3) partial-thickness rotator cuff tears after failed conservative care remains challenging. Arthroscopic repair techniques are often considered with or without subacromial decompression and biological injections. More recently, a bioinductive bovine collagen patch (Regeneten; Smith & Nephew, Memphis, TN, USA) has been proposed to create a healing response and thicken the injured tendon. Although promising early results have been shown, previous studies lacked control subjects or comparison to other surgical treatments. The purpose of this study was to compare the reoperation rates of arthroscopic débridement and repair without a bioinductive collagen patch vs. arthroscopic débridement and repair with a bioinductive collagen patch in patients with high-grade partial-thickness rotator cuff tears in whom a minimum of 6 months of nonoperative treatment failed. METHODS: Thirty-two patients with high-grade partial-thickness supraspinatus tears were treated with surgical repair with a bioinductive patch. A control group of 32 patients with high-grade partial-thickness supraspinatus tears treated with débridement or tear completion and repair without a bioinductive patch was selected and matched for age, sex, and tear size. Patients were followed up at regular intervals of 6 weeks, 12 weeks, and 6 months postoperatively, and range of motion was assessed at respective clinic visits. Stiffness and reoperations were compared between groups. RESULTS: Postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group (P < .001). All 6 reoperations in the patch group were performed to address stiffness. There were no differences in race, smoking status, or diabetes between groups (P > .05). CONCLUSION: Patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required.

Mental health status, not resilience, influences functional recovery after arthroscopic rotator cuff repairs.

BACKGROUND: Recent literature has shown the importance of patient psychosocial status in overcoming stressful events, such as surgery. Resilience, the ability to "bounce back" from adversity, has been recently correlated to outcomes following arthroscopic rotator cuff repair (RCR). Overall mental well-being has also been shown to be important because patients with clinical depression and anxiety may have worse outcomes. Substantial clinical benefit (SCB) is the threshold of outcome improvement that a patient perceives as considerable. The purpose of this study was to assess the influence of preoperative resilience, mental health status, and rotator cuff tear size on patient outcome recovery measured by the American Shoulder and Elbow Surgeons (ASES) score. METHODS: Patients undergoing arthroscopic RCR performed from 2016 through 2019 at a single tertiary institution by fellowship-trained sports surgeons with a high-volume shoulder practice were included. The Brief Resilience Scale (BRS) score and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Score (MCS) were collected preoperatively. ASES scores were obtained preoperatively, as well as 6 and 12 months postoperatively. Patients were divided into 2 groups based on the SCB threshold of 87 for the ASES score based on validated, established literature. Rotator cuff tear size was classified as small (≤3 cm) or large (>3 cm). VR-12 MCS, BRS, and ASES scores were compared at baseline, 6 months, and 1 year using separate mixed-model analyses of variance between the tear size and SCB groups. For ASES score comparison, the VR-12 MCS was used as a covariate to account for differences in baseline mental status. RESULTS: RCR was performed in 119 patients, with an average age of 61 years (standard deviation, 10 years). There were 71 male and 48 female patients. At 6 months, 43% of patients met the SCB threshold. The VR-12 MCS was significantly different between RCR patients who met the SCB threshold for the ASES score and those who did not at 6 and 12 months for large rotator cuff tears (P = .001) but not small tears (P = .07). The BRS score was not different between the tear size and SCB groups at any time point (P = .12). CONCLUSION: Our results show that patients who met the SCB threshold at 6 months postoperatively after arthroscopic RCR demonstrated higher preoperative VR-12 MCS values; however, higher preoperative BRS scores were not seen in those meeting the SCB threshold. In fact, when baseline VR-12 MCS values were accounted for in patients with large rotator cuff tears, the differences in ASES scores normalized. This finding suggests that baseline mental health status, as measured by the VR-12 MCS, significantly influenced patients' functional recovery following RCR. Future research should focus on preoperative psychosocial well-being to optimize postoperative outcomes.

Single shot interscalene regional anesthesia provides noninferior analgesia and decreased complications compared with an indwelling catheter for arthroscopic and reconstructive shoulder surgery.

BACKGROUND: There is an abundance of literature comparing the efficacy, safety, and complication rates of regional anesthesia in shoulder surgery. The purpose of this study was to compare analgesia efficacy, and complication rates between single shot and continuous catheters in patients undergoing arthroscopic or reconstructive shoulder surgery in a large cohort. METHODS: Consecutive patients (n = 1888) who underwent shoulder arthroplasty or arthroscopic shoulder surgery and had regional anesthesia were included. Patients had either a single-shot interscalene block (SSIB) or an SSIB with a continuous interscalene nerve block with a catheter (CIB). The decision for SSIB or CIB was selected based on patient risk factors and surgeon preference. Patients received phone calls on postoperative days 1, 2, 7, and 14 to assess for pain levels (numeric rating scale [NRS]) and complications. RESULTS: One hundred sixty patients received SSIB, and 1728 patients received CIB. The postoperative NRS scores at day 1 were also similar. There were 3 complications (2%) in the SSIB group and 172 complications (10%) in the CIB group. Ten patients in the CIB group required emergency department (ED) visits secondary to block complications compared with no ED visits in the SSIB group. CONCLUSION: In 1888 consecutive patients, SSIB and CIB provided similar pain relief following shoulder surgery. However, patients who received CIB had significantly more complications and ED visits than patients who received SSIB. The potential benefits of longer pain relief may not outweigh the risks of CIB vs. SSIB in common shoulder procedures.

Predicting Recurrent Care Seeking of Physical Therapy for Musculoskeletal Pain Conditions.

OBJECTIVE: Musculoskeletal pain conditions are a leading cause of pain and disability internationally and a common reason to seek health care. Accurate prediction of recurrence of health care seeking due to musculoskeletal conditions could allow for better tailoring of treatment. The aim of this project was to characterize patterns of recurrent physical therapy seeking for musculoskeletal pain conditions and to develop a preliminary prediction model to identify those at increased risk of recurrent care seeking. DESIGN: Retrospective cohort. SETTING: Ambulatory care. SUBJECTS: Patients (n = 578,461) seeking outpatient physical therapy (United States). METHODS: Potential predictor variables were extracted from the electronic medical record, and patients were placed into three different recurrent care categories. Logistic regression models were used to identify individual predictors of recurrent care seeking, and the least absolute shrinkage and selection operator (LASSO) was used to develop multivariate prediction models. RESULTS: The accuracy of models for different definitions of recurrent care ranged from 0.59 to 0.64 (c-statistic), and individual predictors were identified from multivariate models. Predictors of increased risk of recurrent care included receiving workers' compensation and Medicare insurance, having comorbid arthritis, being postoperative at the time of the first episode, age range of 44-64 years, and reporting night sweats or night pain. Predictors of decreased risk of recurrent care included lumbar pain, chronic injury, neck pain, pregnancy, age range of 25-44 years, and smoking. CONCLUSION: This analysis identified a preliminary predictive model for recurrence of care seeking of physical therapy, but model accuracy needs to improve to better guide clinical decision-making.

Factors influencing time to return to sport following clavicular fractures in adolescent athletes.

BACKGROUND: There is a trend toward increased surgical treatment of displaced clavicle fractures in the adolescent population presumably because of extrapolation of adult-derived best practice guidelines. The purpose of this study was to compare return to sport between nonoperative and operative treatment of clavicle fractures in high school athletes. METHODS: A retrospective review of clavicle fractures sustained in scholastic athletes participating in school-sponsored athletics in the upstate South Carolina was performed from 2015 to 2019. Injury circumstances, demographics, radiographs, treatment, and return to sport data were documented for all patients. Radiographs were evaluated for fracture location, comminution, displacement, shortening, and angulation. Patients were followed until complete return to sport, and results were compared based on sport participation, injury mechanism, fracture morphology, treatment type, and time to return to sport. RESULTS: Forty-seven patients (44 were male; average age 15.6 years) were included who all returned to sport within the original or subsequent season. Thirty-six patients (73%) were managed conservatively (30 middle third fractures, 4 medial third fractures, 2 distal third fractures), whereas 11 were managed surgically (11 middle third fractures). Eighty-one percent of fractures occured in collision athletes (55% in football). There was no difference in time loss based on participating in collision vs. noncontact sports (P = .4). Conservatively managed fractures returned to sport faster (61 ± 38 days vs. 100 ± 49 days; P = .008) compared with surgically managed patients. Fracture displacement ≥100% (100 ± 51 days vs. 54 ± 27 days; P = .001), greater comminution (128 ± 50 days vs. 59 ± 31 days; P = .001), and angulation (86 ± 52 days vs. 54 ± 22 days; P = .001) all were statistically significant for slower return to sport. Athletes presenting with clavicular shortening <2 cm returned to sport within a similar time frame as athletes with ≥2 cm (P = 0.1). CONCLUSION: Our results show that adolescent athletes with clavicular fractures predictably return to athletics, including collision sports. Athletes conservatively managed returned 40% faster than those with surgery. However, this appears to be associated with the severity and complexity of fractures treated surgically. This study provides evidence to counsel adolescent athletes following clavicular fractures on return to sport expectations.

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk.

INTRODUCTION: Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations. METHODS: A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation. RESULTS: Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χ2 = 8.9, P = .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P = .11). DISCUSSION: Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk. CONCLUSION: Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Development and internal validation of a humeral torsion prediction model in professional baseball pitchers.

BACKGROUND: Humeral torsion (HT) has been linked to pitching arm injury risk after controlling for shoulder range of motion. Currently measuring HT uses expensive equipment, which inhibits clinical assessment. Developing an HT predictive model can aid clinical baseball arm injury risk examination. Therefore, the purpose of this study was to develop and internally validate an HT prediction model using standard clinical tests and measures in professional baseball pitchers. METHODS: An 11-year (2009-2019) prospective professional baseball cohort was used for this study. Participants were included if they were able to participate in all practices and competitions and were under a Minor League Baseball contract. Preseason shoulder range of motion (external rotation [ER], internal rotation [IR], horizontal adduction [HA]) and HT were collected each season. Player age, arm dominance, arm injury history, and continent of origin were also collected. Examiners were blinded to arm dominance. An a priori power analysis determined that 244 players were needed for accurate prediction models. Missing data was low (<3%); thus, a complete case analysis was performed. Model development followed the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) recommendations. Regression models with restricted cubic splines were performed. Following primary model development, bootstrapping with 2000 iterations were performed to reduce overfitting and assess optimism shrinkage. Prediction model performance was assessed through root mean square error (RMSE), R2, and calibration slope with 95% confidence intervals (CIs). Sensitivity analyses included dominant and nondominant HT. RESULTS: A total of 407 professional pitchers (age: 23.2 [standard deviation 2.4] years, left-handed: 17%; arm history prevalence: 21%) participated. Predictors with the highest influence within the model include IR (0.4, 95% CI 0.3, 0.5; P < .001), ER (-0.3, 95% CI -0.4, -0.2; P < .001), HA (0.3, 95% CI 0.2, 0.4; P < .001), and arm dominance (right-handed: -1.9, 95% CI -3.6, -0.1; P = .034). Final model RMSE was 12, R2 was 0.41, and calibration was 1.00 (95% CI 0.94, 1.06). Sensitivity analyses demonstrated similar model performance. CONCLUSIONS: Every 3° of IR explained 1° of HT. Every 3° of ER explained 1° less of HT, and every 7° of HA explained 1° of HT. Right-handers had 2° less HT. Models demonstrated good predictive performance. This predictive model can be used by clinicians to infer HT using standard clinical test and measures. These data can be used to enhance professional baseball arm injury examination.

Athletes diagnosed with anterior and posterior shoulder instability display different chief complaints and disability.

BACKGROUND: Anterior shoulder instability is a common complaint of young athletes. Posterior instability in this population is less well understood, and the standard of care has not been defined. The purpose of the study is to compare index frequency, treatment choice, and athlete disability following an incident of anterior or posterior shoulder instability in high school and collegiate athletes. METHODS: A total of 58 high school and collegiate athletes (n=30 athletes with anterior instability; n=28 athletes with posterior instability) were included. Athletes suffering from a traumatic sport-related shoulder instability episode during a team-sponsored practice or game were identified by their school athletic trainer. Athletes were referred to the sports medicine physician or orthopedic surgeon for diagnosis and initial treatment choice (operative vs. nonoperative). Athletes diagnosed with traumatic anterior or posterior instability who completed the full course of treatment and provided pre- and post-treatment patient-reported outcome measures were included in the study. The frequency of shoulder instability was compared by direction, mechanism of injury (MOI), and treatment choice through χ2 analyses. A repeated measures analysis of variance was used to compare the functional outcomes by treatment type and direction of instability (α = 0.05). RESULTS: Athletes diagnosed with anterior instability were more likely to report a chief complaint of instability (70%), whereas those diagnosed with posterior instability reported a primary complaint of pain interfering with function (96%) (P = .001). The primary MOI classified as a contact event was similar between anterior and posterior instability groups (77% vs. 54%, P = .06) as well as the decision to proceed with surgery (60% vs. 72%, P = .31). In patients with nonoperative care, athletes with anterior instability had significantly more initial disability than those with posterior instability (32±6.1 vs. 58±8.1, P = .001). Pre- and post-treatment Penn Shoulder Scores for athletes treated with early surgery were similar (P > .05). There were no differences in functional outcomes at discharge in those treated nonoperatively regardless of direction of instability (P = .24); however, change in Penn score was significantly greater in those with anterior (61±18.7) than those with posterior (27 ± 25.2) instability (P = .002). CONCLUSION: Athletes with anterior instability appear to have different mechanisms and complaints than those with posterior instability. Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during course of care.

Preseason shoulder range of motion screening and in-season risk of shoulder and elbow injuries in overhead athletes: systematic review and meta-analysis.

OBJECTIVE: To characterise whether preseason screening of shoulder range of motion (ROM) is associated with the risk of shoulder and elbow injuries in overhead athletes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Six electronic databases up to 22 September 2018. ELIGIBILITY CRITERIA: Inclusion criteria were (1) overhead athletes from Olympic or college sports, (2) preseason measures of shoulder ROM, (3) tracked in-season injuries at the shoulder and elbow, and (4) prospective cohort design. Exclusion criteria were (1) included contact injuries, (2) lower extremity, spine and hand injuries, and (3) full report not published in English. RESULTS: Fifteen studies were identified, and they included 3314 overhead athletes (baseball (74.6%), softball (3.1%), handball (16.1%), tennis (2.0%), volleyball (2.0%) and swimming (2.2%)). Female athletes are unrepresented (12% of the overall sample). Study quality ranged from 11 to 18 points on a modified Downs and Black checklist (maximum score 21, better quality). In one study, swimmers with low (<93°) or high (>100°) shoulder external rotation were at higher risk of injuries. Using data pooled from three studies of professional baseball pitchers, we showed in the meta-analysis that shoulder external rotation insufficiency (throwing arm <5° greater than the non-throwing arm) was associated with injury (odds ratio=1.90, 95% confidence interval 1.24 to 2.92, p<0.01). CONCLUSION: Preseason screening of shoulder external rotation ROM may identify professional baseball pitchers and swimmers at risk of injury. Shoulder ROM screening may not be effective to identify handball, softball, volleyball and tennis players at risk of injuries. The results of this systematic review and meta-analysis should be interpreted with caution due to the limited number of studies and their high degree of heterogeneity. PROSPERO REGISTRATION NUMBER: CRD42017072895.