The Distress and Risk Assessment Method predicts postoperative narcotic use in patients undergoing rotator cuff repair.

BACKGROUND: The Distress and Risk Assessment Method (DRAM) predicts poor outcomes in spine, hip, and knee surgery. Unlike other areas of orthopedic surgery, DRAM scores are not predictive of lower postoperative patient-reported outcomes after arthroscopic rotator cuff repair (RCR). PURPOSE: As concerns for opioid dependence and abuse grow, the purpose of this study was to analyze the correlation between preoperative DRAM scores, modified Zung scores, and postoperative narcotic use in patients who underwent arthroscopic RCR. MATERIALS AND METHODS: This prospective cohort study identified and enrolled patients >18 years of age with full-thickness rotator cuff tears at a single institution. Patients with prior shoulder surgery, greater than 1-tendon RCR, and preoperative narcotic use were excluded. One-hundred and fifty patients were enrolled, with 114 (76%) completing all preoperative and postoperative questionnaires. Preoperative DRAM scores were collected from every patient. Postoperative narcotic use was evaluated via survey and converted to total morphine equivalents. RESULTS: Increased preoperative DRAM scores predicted higher postoperative morphine equivalent units (P = .002, r = 0.29). When dividing patients into those <17 or ≥17 on the modified Zung score, 44 of 114 (39%) met criteria for "at risk or depressed." This group showed a statistically significant trend toward higher postoperative morphine equivalent unit intake (P = .004). CONCLUSION: Baseline psychological distress (DRAM) can predict narcotic requirements after RCR and serve as a powerful tool to identify patients at risk for increased narcotics requirements postoperatively. In our cohort, 39% of patients showed evidence of baseline depression, which highlights a potential role of the modified Zung score to identify patients in need of preoperative psychological counseling.

Baseline Cartilage Thickness and Meniscus Extrusion Predict Longitudinal Cartilage Loss by Quantitative Magnetic Resonance Imaging: Data From the Osteoarthritis Initiative.

OBJECTIVE: This study aimed to assess how meniscus damage and baseline cartilage thickness influence the rate of cartilage loss and knee pain. METHODS: Of 4796 participants in the Osteoarthritis Initiative, 86 had baseline and 48-month follow-up quantitative magnetic resonance imaging data for medial compartment cartilage thickness. Baseline meniscus pathology was scored by a musculoskeletal radiologist using Whole-Organ Magnetic Resonance Imaging Score. Findings were correlated with 72-month Knee injury and Osteoarthritis Outcome Score. RESULTS: Univariate analysis showed cartilage change was not influenced by demographic variables. Multivariable regression revealed that initial cartilage thickness (-1.07 mm at 48 months for every 1 mm decrease at baseline, P < 0.001) and meniscus extrusion (-0.33 mm if present at baseline, P < 0.001) were the strongest predictors of medial compartment cartilage thickness at 48 months. Knee injury and Osteoarthritis Outcome Score pain scores did not correlate with cartilage loss. CONCLUSIONS: Baseline cartilage thickness and meniscus extrusion are important and independent predictors for accelerated cartilage loss. However, the degree of cartilage loss did not correlate with midterm change in clinical outcome scores.

Post-operative Urinary Dysfunction Following Shoulder Surgery: Rates and Risk Factors.

Background: Post-operative urinary retention (POUR) and dysfunction are recognized complications following orthopaedic surgery. Recent literature has focused on urinary retention and its associated complications following hip and knee reconstruction and lower extremity surgery. There is a paucity of literature focusing on POUR and shoulder surgery. The purpose of this study is to describe the rates of urinary dysfunction in patients undergoing shoulder surgery as well as the associated risk factors. Methods: This was a single institution, prospective cohort study. Eligibility criteria included patients older than 50 years of age undergoing open or arthroscopic shoulder surgery. The primary outcome was the American Urological Association (AUA) symptom score (7 questions total scored 0-5, total 35 points max) administered before and after surgery. Higher scores reflect worse urinary dysfunction. Intra-operative data such as type of surgery, type of anesthesia, use of anticholinergics, peripheral nerve block, length of case, and amount of intravenous fluids were collected. Results: Of 194 patients, the mean age was 61.4 years (Standard Deviation (S.D.) = 13.0)) and the average BMI was 29.2 (S.D. = 5.6). The sample was 35.6% female. Overall, 46.4% reported worse AUA scores post-operatively within the first 3 to 5 days, including 4.1% of which were clinically defined as "moderately worse" (>5 point worse) or "much worse" (>11 points worse). Worse preoperative AUA scores correlated with worse postop AUA score on linear regression analysis (r=0.883, P<0.0001). Males with a history of BPH showed a statistically significant positive association with worsening urinary dysfunction postoperatively (P=0.039). Four patients (2.1%) required postoperative catheterization. A significantly higher percentage of patients with preoperative AUA scores of ≥11 experienced worsening of urinary function post-operatively (P=0.04). Conclusion: Worsening of urinary function following shoulder surgery is common. The AUA score may be used to identify at-risk patients and to track changes in urinary function post-operatively. Men with a diagnosis of BPH are at particularly high risk. Further investigation is needed to elucidate the impact of urinary dysfunction on patient outcomes, satisfaction, and cost as well as the role of prophylactic medications.

Osseous changes following reverse total shoulder arthroplasty combined with latissimus dorsi transfer: a case series.

BACKGROUND: This is the first report on the incidence of proximal humerus osseous changes and associated clinical consequences in reverse total shoulder arthroplasty combined with a latissimus dorsi tendon transfer (RTSA+LDT). METHODS: A multicenter, retrospective review identified all patients who had undergone a primary RTSA+LDT and had at least 3-month radiographic follow-up between 2012 and 2017. Data collection included demographics, oral steroid use, repair technique for LDT fixation, radiographic humeral osseous changes, complications, and need for revision surgery. RESULTS: Twenty-four patients were included with an average age of 70.7 ± 7.9 years and follow-up of 16.3 (3-50) months. Ten patients (41.7%) developed osseous changes at the transfer location. There was no increased risk of developing osseous changes based on the surgical fixation technique (P = .421). Average time to earliest radiographic detection of osseous changes was 2.7 ± 1.7 months, with all changes occurring at or before 6 months. Two patients developed proximal humerus fractures, of which 1 had osseous changes through which the fracture occurred. DISCUSSION: RTSA+LDT may place the proximal humeral cortex at greater risk than previously described. Using a long-stem prosthesis in the setting of RTSA+LDT may limit the consequences of this complication.