Humeral stem loosening is not always prosthetic joint infection.

BACKGROUND: Aseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening. METHODS: Our institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting scoring criteria. International Consensus Meeting classifications of PJI "unlikely" and "possible" were considered aseptic, and PJI "probable" and "definite" were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening. RESULTS: Forty-six patients with 48 shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, 13 cases (27%) were classified as probable PJI, 4 cases (8%) were classified as possible PJI, and 21 cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (P = .005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (P < .001). CONCLUSION: Fifty-two % of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening.

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears.

BACKGROUND: Nonsurgical management of chronic, degenerative rotator cuff tears (RCTs) can be an effective treatment strategy, but there is limited evidence to support conservative treatment of acute, traumatic RCTs. The objective of this study was to assess clinical outcomes and predictors of treatment success in patients with traumatic RCTs who elected for initial nonoperative treatment. METHODS: Patients from a single institution were retrospectively identified using diagnostic codes for traumatic RCTs followed by confirmed initial treatment with ≥2 months of physical therapy. The exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on magnetic resonance imaging. At minimum 2-year follow-up, patients were contacted by telephone to collect interval surgical history and standardized patient-reported outcomes. Physical therapy was considered to have failed in all those who underwent surgical treatment and those with satisfaction ratings of "moderately dissatisfied" or "very dissatisfied." RESULTS: Follow-up outcomes were obtained in 40 of 49 patients (82%), with an average follow-up time of 4.2 years. Of the RCTs, 9 (22%) were small (<1 cm), 22 (54%) were medium (>1 cm to <3 cm), and 9 (22%) were large (>3 cm to <5 cm). Grade I fatty infiltration was seen on 25% of magnetic resonance imaging scans (n = 10). Rotator cuff repair was performed in 18 patients (45%) following an average of 6 months of nonoperative treatment (range, 3-12 months). Nonoperative treatment was determined to have failed in 23 of 40 patients (58%) in total. Conservative management was more likely to fail in patients with multiple tendons torn (P = .014). Tear size and retraction were not significantly different between patients who underwent surgery and those who did not. Patients who underwent surgical management had an 83% satisfaction rate at final follow-up compared with a 55% satisfaction rate for patients who did not undergo surgery (P = .054). There was no statistically significant difference in the American Shoulder and Elbow Surgeons score or visual analog scale score between these groups. Although patients who underwent surgery had a higher mean Single Alpha Numeric Evaluation score (86.3 vs. 75.1, P = .041), this difference was below the previously established minimal clinically important difference. CONCLUSION: Nonoperative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs.

Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus.

BACKGROUND: Hyperglycemia is a known risk factor for tendon degeneration due to oxidative stresses from production of advanced glycosylation end products. In patients with diabetes mellitus (DM), analysis of glycated hemoglobin (HbA1c) provides a 3-month window into a patient's glucose control. No guidelines exist for ideal preoperative HbA1c and glucose control prior to arthroscopic rotator cuff repair. This study evaluated if a critical HbA1c level is associated with reoperation following arthroscopic rotator cuff repair. METHODS: We retrospectively evaluated patients with DM who underwent primary arthroscopic rotator cuff repair from January 2014 to December 2018 at a single institution. Patients required a preoperative HbA1c within 3 months of surgery. Medical records were queried to evaluate for reoperation and identify the subsequent procedures performed. Univariate statistical analysis was performed to assess factors associated with reoperation (P < .05 considered significant). Threshold, area under the curve (AUC), analysis was performed to assess if a critical HbA1c value was associated with reoperation. RESULTS: A total of 402 patients met inclusion criteria. Patients had an average age of 65.5 years (range 40-89) at time of surgery; 244 (60.6%) patients were male; and average body mass index was 32.96 ± 5.81. Mean HbA1c was 7.36 (range 5.2-12). Thirty-three patients (8.2%) underwent subsequent reoperation. Six patients (1.5%) underwent capsular release and lysis of adhesions, 20 patients (5.0%) underwent a revision rotator cuff surgery, combination revision rotator cuff repair and lysis of adhesions, graft-augmented revision repair, or superior capsular reconstruction, and 7 patients (1.7%) underwent revision to reverse shoulder arthroplasty (1.7%). There were no cases of reoperation for infection. On AUC analysis, no critical HbA1c value was identified to predispose to reoperation. Interestingly, elevated preoperative American Society of Anesthesiologists (ASA) physical status classification score (2.8 vs. 2.28, P = .001) was associated with a higher reoperation rate. DISCUSSION: In patients with DM, preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation. Stable glycemic control is important to a patient's overall health and may play a role in minimizing postoperative medical complications, but an elevated preoperative HbA1c should not be a strict surgical contraindication for arthroscopic rotator cuff repair. In patients with DM, an elevated ASA score is associated with an increased rate of subsequent reoperation; diabetic patients should be counseled accordingly.

Postoperative stiffness after reverse total shoulder arthroplasty.

Purpose: The purpose of this study was to evaluate the rate and risk factors for stiffness after reverse shoulder arthroplasty and the ramifications on the patient-reported outcomes. Method: A consecutive series of patients who underwent reverse shoulder arthroplasty were prospectively followed for one year. Passive range of motion was measured preoperatively and at regular intervals postoperatively. Patients with passive forward elevation of less than 100° or passive external rotation of less than 30° were defined as stiff. Radiographic parameters and postoperative patient-reported outcome scores were collected. Results: Seventy-six patients were available for review. The prevalence of postoperative stiffness following reverse shoulder arthroplasty was 47% at three months, 31% at six months, and 25% at one year. Preoperative shoulder stiffness was associated with three-month postoperative stiffness only. In patients with one-year stiffness, smaller (p = 0.03) and less lateralized glenospheres (p = 0.024) were more common. Stiffness was not associated with one-year patient-reported outcome scores. Conclusion: Stiffness is common after reverse shoulder arthroplasty and often improves at one-year after surgery. Implant design and selection may be important determinants of passive range of motion. While stiffness does not appear to influence patient-reported outcome scores, one of four patients will potentially have stiffness one year following reverse shoulder arthroplasty.Level of evidence: Level III; retrospective study.

Ambulatory shoulder arthroplasty provides a mild reduction in overall cost compared with inpatient shoulder arthroplasty cost of ambulatory shoulder arthroplasty.

HYPOTHESIS: The purpose of this study was to determine the relative cost difference of inpatient vs. ambulatory total shoulder arthroplasty (TSA) procedures. METHODS: A retrospective case series was performed to identify a consecutive series of patients who underwent primary anatomic or reverse TSA at 2 orthopedic specialty hospitals between September 2015 and August 2020. Those undergoing surgery for fracture or revision were excluded. Itemized facility costs were analyzed with a time-driven activity-based costing model and compared between ambulatory and non-ambulatory procedures. Ambulatory patients were defined as those admitted and discharged on the same calendar day. All other patients were considered non-ambulatory. RESULTS: A total of 1027 patients were analyzed, comprising 38 ambulatory patients (3.7%) and 989 non-ambulatory patients (96.3%). There was a higher proportion of anatomic TSA than reverse shoulder arthroplasty in the ambulatory group (81.6% vs. 51.7%, P < .0001). Overall, there was no difference in cost between the 2 groups ($8832 vs. $8841, P = .97). However, personnel costs were greater in the non-same-day group ($1895 vs. $2743, P < .0001) whereas supply costs were less ($6937 vs. $6097, P < .0003). When implant costs were excluded, outpatient shoulder arthroplasty provided a cost savings of $745. CONCLUSION: Ambulatory shoulder arthroplasty provides a mild cost savings of $745 after controlling for fixed costs. This is much less dramatic than previously reported and should raise concern as shoulder arthroplasty continues to be targeted by payers as a potential for cost savings through decreased reimbursement.

Hematoma following total elbow arthroplasty: incidence, management, and outcomes.

INTRODUCTION: This study investigates the incidence, risk factors for, and clinical outcomes of hematoma following total elbow arthroplasty. METHODS: We retrospectively reviewed patient and surgical characteristics as predictors of post-operative hematoma in 382 total elbow arthroplasty (196 primary, 157 revision, and 29 conversion) between May 2004 and February, 2017. For comparison of outcomes, cases were matched (1:2) with controls by age, gender, type of surgery, and surgical indication. RESULTS: Nineteen post-operative hematomas (5.0%; 19/382) were identified. Total elbow arthroplasty for post-traumatic arthritis (6.7%; 4/60), aseptic loosening (7.9%; 3/38), sequelae of periprosthetic joint infection (6.1%; 5/81), and non-union (28.6%; 2/7) had the highest incidence of hematoma. Clinic aspiration and compressive wrap was performed in 14 patients and avoided a return to the operating room in 78.6% (11/14). Seven patients (36.8%) required a return to the operating room, of which five (71.4%) had positive cultures and required treatment for prosthetic joint infection. Compared to the matched controls, hematoma formation predicted a higher rate of reoperation (36.8% versus 7.9%; p = 0.007) and a higher rate of subsequent prosthetic joint infection (35.7% versus 0%; p = 0.008). CONCLUSION: Hematoma formation is associated with both prosthetic joint infection and return to the operating room after total elbow arthroplasty. Strategies to prevent hematoma formation after total elbow arthroplasty may reduce complication rates.

Single Assessment Numeric Evaluation Correlates with American Shoulder and Elbow Surgeons Score for Common Elbow Pathology: A Retrospective Cohort Study.

BACKGROUND: There are currently a variety of patient-reported outcomes (PROs) for elbow pathology, without any established gold standard. The Single Assessment Numeric Evaluation (SANE) is a single question assessment of the patient's perceived overall function compared with normal. The SANE score has been correlated with PROs from the shoulder and knee literature. PURPOSE: To correlate the SANE score for a variety of elbow pathologies with a traditionally reported elbow outcome measure, the American Shoulder and Elbow Surgeons-Elbow score (ASES-E). STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A retrospective review was performed of all patients identified at a single center between April 2016 and January 2019 who presented as a new patient with elbow pathology. All patients prospectively completed the ASES-E along with the SANE score for elbow (SANE-E) at the time of initial consultation. Spearman correlations (r) were performed to evaluate the correlation between the ASES-E and the SANE-E score for specific elbow pathology, along with descriptive data such as age, sex, and chronicity of the problem. RESULTS: A total of 555 patients (166 women, 29.9%) with a mean ± SD age of 51.0 ± 11.7 years with the diagnoses of medial epicondylitis (n = 72; 13.0%), lateral epicondylitis (n = 224; 40.4%), biceps tendon rupture (n = 139; 25.0%), triceps tendon rupture (n = 21; 3.8%), and elbow arthritis (n = 99; 17.8%) were included in this analysis. There was moderate correlation between the SANE-E and the ASES-E (r = 0.623; P < .001), with strongest correlation with the visual analog scale (VAS) (r = -0.518; P < .001) compared with any individual question and moderate to strong correlations based on specific diagnoses. SANE-E and ASES-E scores for the entire cohort were 42.9 ± 26.7 and 56.9 ± 21.4, respectively (P < .001). Age (r = 0.027; P = .526), sex (r = 0.026; P = .555), VAS (r = -0.106; P = .013), and chronicity of the problem (r = -0.037; P = .384) were not found to be correlated with differences in ASES-E and SANE-E. CONCLUSION: The SANE-E score is a simple way to assess patient-perceived function relative to normal. The findings of this study demonstrated moderate to strong correlation between the ASES-E and the SANE-E score for a variety of commonly encountered elbow conditions.

Early repair of traumatic rotator cuff tears improves functional outcomes.

BACKGROUND: The impact of surgical timing on outcomes involving traumatic rotator cuff tears (RCTs) remains uncertain. The purpose of this study was to determine how functional outcomes are affected by surgical timing in traumatic RCTs. METHODS: We performed a retrospective review of patients with repair of traumatic full-thickness RCTs. Preoperative magnetic resonance imaging scans were evaluated by 2 blinded reviewers to measure RCT area and muscular atrophy. Functional outcomes were assessed via the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Simple Shoulder Test score, and visual analog scale (VAS) pain score. Patients were divided into 4 groups based on the time from injury to surgery: 0-2 months (group 1), 2-4 months (group 2), 4-6 months (group 3), and 6-12 months (group 4). Multivariate analysis was performed to assess the impact of surgical timing on functional outcomes. A subanalysis was performed to assess outcomes in patients who underwent surgery within 3 weeks of injury. RESULTS: The study included 206 patients (150 men and 56 women) with a mean age of 60.0 ± 9.7 years and a minimum of 24 months' clinical follow-up (mean, 35.5 months; range, 24-54.4 months). The average tear area was 8.4 ± 6.3 cm2 in group 1 (66 patients), 5.8 ± 5.1 cm2 in group 2 (76 patients), 5.1 ± 4.6 cm2 in group 3 (29 patients), and 3.7 ± 3.1 cm2 in group 4 (35 patients) (P < .001). There were significant differences between the 4 cohorts in the final postoperative ASES score (P = .030) and VAS pain score (P = .032). The multivariate regression demonstrated that patients who underwent surgery within 4 months of injury had estimated improvements of 10.3 points in the ASES score (P = .008), 1.8 points in the Simple Shoulder Test score (P = .001), 8.6 points in the SANE score (P = .033), and 0.93 points in the VAS pain score (P = .028) compared with patients who underwent surgery later. The subanalysis demonstrated that patients who underwent surgery within 3 weeks of injury (n = 13) had significantly better VAS (P = .003), ASES (P = .008), and SANE (P = .019) scores than patients who underwent surgery at between 3 weeks and 4 months after injury (n = 129). CONCLUSIONS: This study demonstrates that surgical repair of traumatic RCTs results in significant improvements in functional outcomes for all patients; however, patients who undergo surgery within 3 weeks can expect the best functional outcomes, with a drop in function in patients who undergo surgery >4 months after injury.

Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty.

BACKGROUND: Venous thromboembolism (VTE) events are infrequent but potentially catastrophic complications following orthopedic surgery. There is currently a paucity of evidence regarding the role of chemoprophylaxis with low-dose aspirin (acetylsalicylic acid [ASA]) after shoulder arthroplasty. METHODS: We conducted a retrospective review of prospectively collected complications occurring within 90 days of 2394 primary shoulder arthroplasties performed over a 3-year period at a single institution. Patients preoperatively underwent risk stratification into medically high risk, moderate risk, or low risk as part of a standardized navigated-care pathway. For chemoprophylaxis, 81 mg of ASA (low dose) was routinely used once daily for 6 weeks unless alternative medications were deemed necessary by the medical team. Baseline demographic information, medical comorbidities, and postoperative VTE prophylaxis, as well as rates of clinically symptomatic VTE, were assessed. RESULTS: Symptomatic VTE occurred after 0.63% of primary shoulder arthroplasties (15 of 2394). There were 9 patients with deep vein thromboses and 6 with pulmonary embolisms. Eighty-one milligrams of ASA was used in 2141 patients (89.4%), resulting in an overall VTE rate of 0.56%. Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of deep vein thrombosis, asthma, and cardiac arrhythmia were significantly more likely to have a VTE (P < .05). Complications occurred in 4 patients (0.19%) associated with low-dose ASA and 1 patient (0.63%) associated with a novel oral anticoagulant medication. CONCLUSION: Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE.

Traumatic Elbow Instability: How to Fix It and When to Phone a Friend.

Traumatic elbow instability is a difficult condition to manage. Many surgeons consider the elbow a perplexing black box and evaluating damaged structures in the setting of pain and swelling a diagnostic challenge. Injury most commonly occurs from a fall onto an outstretched hand but also results from elbow dislocation, direct trauma, and sporting activities. The injury can initiate on the medial or lateral side, depending on forearm position at the time of injury, and usually follows a predictable pattern, with progressive instability caused by soft-tissue disruption and fractures of the medial or lateral column. Primary medial instability, lateral instability, and combined injury patterns have been described and discussed. Simple elbow dislocations and certain fractures can be managed nonsurgically, whereas complex patterns of instability and fracture-dislocations routinely require surgery. Stiffness and nerve injury are the most common complications and occur from both surgical and nonsurgical management. This chapter describes the diagnosis and management of traumatic elbow instability and the management of its sequela.

Characterizing opioid consumption in the 30-day post-operative period following shoulder surgery: are we over prescribing?

Objectives: The primary aim of this study was to characterize opioid consumption in the first 30 days after shoulder surgery. Secondary aims were to assess patient expectations, pain tolerance, risk factors for increase opioid consumption, and proper disposal of narcotics.Methods: Patients undergoing rotator cuff repair (RCR), anatomic shoulder arthroplasty, reverse shoulder arthroplasty (RSA), distal clavicle resection, or labral surgery were prospectively enrolled. Collected data included demographics, Pain Catastrophizing Scale (PCS), pain tolerance surveys, narcotic use, adverse effects, and disposal method.Results: Eighty patients were included in this study. At 28 days, RCR patients took significantly more 5 mg oxycodone-equivalent pills than RSA patients (18.4 vs. 7.5; p = 0.001). Number of days on narcotics did not differ between groups. By day 14, 73 (92.5%) patients had stopped taking narcotics entirely, with 872 5 mg oxycodone-equivalent pills prescribed in surplus. Ten (14.3%) patients required an additional prescription. There was a significant difference in tobacco use (20% vs. 1.4%; p = 0.04), psychiatric history (50% vs. 5.7%; p = 0.0004) and PCS (12.7 vs. 7.1; p = 0.027) in these patients, with PCS of 12.5 as predictive of requiring another prescription.Conclusion: All patients achieved adequate pain control, with 60 (75%) patients having excess pills. Opioid utilization differed based on surgery - significantly lower use in RSA patients compared to RCR. Only 13 (16.25%) patients required more than 20 5 mg oxycodone-equivalent pills. Tobacco use, history of psychiatric illness, and PCS were risk factors for requiring more prescriptions.

Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference?

BACKGROUND: Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend toward shorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy. METHODS: We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem design were collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft angle were performed. Restoration of the native humeral anatomy was deemed "acceptable" based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed. RESULTS: In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptable HH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P < .001). CONCLUSION: Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.

Identifying surgeon and institutional drivers of cost in total shoulder arthroplasty: a multicenter study.

BACKGROUND: Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. METHODS: A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. RESULTS: Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. CONCLUSIONS: Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.

Quantitative ultrahigh-molecular-weight polyethylene wear in total elbow retrievals.

BACKGROUND: The purpose of this study was to evaluate ultrahigh-molecular-weight polyethylene (UHMWPE) wear and damage from retrieved total elbow arthroplasty components and compare in vivo wear with wear produced in vitro. METHODS: Explanted total elbow components were collected at revision surgery. UHMWPE damage was characterized visually, whereas penetration and wear were quantified using micro-computed tomography and gas pycnometry. Volumetric wear rates were compared with historical hip data, and wear data were compared with reported in vitro wear test data. RESULTS: Humeral bushing damage primarily occurred in the form of burnishing, scratching, and pitting at the articular face in the region of contact with the ulnar component. Wear of the ulnar bushings was concentrated on the edge of the component at the point of contact with the axis pin. Pitting and embedded debris were dominant damage modes, in addition to burnishing and delamination. Backside wear was negligible. The median linear penetration rates of the lateral, medial, and ulnar bushings were 0.14 mm/yr (range, 0.01-0.78 mm/yr), 0.12 mm/yr (range, 0.03-0.55 mm/yr), and 0.11 mm/yr (range, 0.01-0.69 mm/yr), respectively. The volumetric wear rates of the lateral, medial, and ulnar bushings were 5.5 mm3/yr (range, 0.7-37.2 mm3/yr), 5.9 mm3/yr (range, 0.6-25.5 mm3/yr), and 5.5 mm3/yr (range, 1.2-51.2 mm3/yr), respectively. CONCLUSIONS: The observed wear rates were similar to those reported in well-functioning total hip replacement patients with conventional UHMWPE bearings. We found limitations in reported in vitro testing resulting in wear that was not consistent with our retrieval data. We recommend further investigation to clinically validate in vitro simulation to provide appropriate loading protocols for elbow wear simulation.

Cutibacterium acnes is less commonly identified by next-generation sequencing than culture in primary shoulder surgery.

INTRODUCTION: High rates of positive Cutibacterium acnes cultures from primary shoulder surgery make positive cultures in the revision surgery setting difficult to interpret. Our goal was to determine concordance between culture and next-generation sequencing techniques for identification of C. acnes from primary shoulder surgery. METHODS: Patients undergoing shoulder arthroscopy for rotator cuff tear or primary anatomic shoulder arthroplasty for osteoarthritis were prospectively enrolled. Specimens were sent for culture (aerobic and anaerobic) and next-generation sequencing. For next-generation sequencing, the entire microbial DNA was sequenced in order to identify pathogens within the sample. RESULTS: Our cohort consisted of 90 patients (45 patients in the osteoarthritis group and 45 patients in the rotator cuff tear group). At least one sample was positive for C. acnes in 18 (20%) cases by culture and in 14 (15.6%) cases by next-generation sequencing (p = 0.559). Four (22.2%) of the 18 cases with positive C. acnes cultures also had C. acnes identified by next-generation sequencing (kappa = 0.238). There was no difference in C. acnes identification rates between osteoarthritis and rotator cuff tear groups. CONCLUSIONS: There was limited concordance between culture and next-generation sequencing for C. acnes identification. Further studies are needed to determine the potential for next-generation sequencing as a diagnostic tool.

Humeral-sided Radiographic Changes Following Reverse Total Shoulder Arthroplasty.

BACKGROUND: We sought to characterize humeral-sided radiographic changes at a minimum of 2 years after reverse shoulder arthroplasty (RSA) to determine their association with specific implantation techniques. METHODS: The immediate and most recent postoperative anteroposterior radiographs of 120 shoulders with primary RSA and a minimum of 2-years of radiographic follow-up were analyzed (mean follow-up 35.2 months). Stress shielding was evaluated by measuring cortical thickness at 4 different locations. Three independent examiners evaluated radiographs for humeral osteolysis, radiolucent lines, stress shielding, stem loosening, and scapular notching. RESULTS: The cortical diameter, marker of external stress shielding, significantly decreased from initial to most recent measurement (P<0.001), but did not differ between cemented and uncemented groups. Cemented stems had significantly more osteolysis and radiolucent lines; uncemented stems had significantly more internal stress shielding (P<001). The presence of scapular notching was significantly correlated with the presence of humeral osteolysis (P<0.001). Three (2.5%) stems were deemed "at risk" for loosening and 2 (1.7%) were loose. CONCLUSION: Cemented humeral stems were associated with an increased rate of radiolucent lines and osteolysis, whereas uncemented stems were associated with more internal stress shielding. Humeral cortical thickness significantly decreased over time regardless of fixation. There was an association between scapular notching and increased humeral osteolysis.

Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model.

INTRODUCTION: The ability to predict successful outcomes is important for patient satisfaction and optimal results after shoulder arthroplasty. We hypothesize that a medical-social scoring tool will predict resource requirements in doing total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of 453 patients undergoing TSA was undertaken. Preoperatively, medical and social surveys were completed by each patient. Demographics, comorbidity scores, hospital course, postdischarge disposition, and readmissions were collected. RESULTS: The average length of stay was 1.6 days (0 to 7). There was an association with utilization of home care or inpatient rehabilitation and both the medical (7.3 versus 3.9; P = 0.0002) and social (7.1 versus 3.4; P < 0.0001) components of the survey. There was a weak correlation between hospital length of stay and the social component of the survey (R = 0.29; P < 0.001), but not the medical component (R = 0.04; P = 0.38). No variable was predictive of readmission. Social score of eight was found to be predictive of postoperative requirement of home care or rehabilitation. CONCLUSION: This study found that Medical and Social Survey Scores can stratify patients who are at risk of requiring more advanced postdischarge care and/or a longer hospital stay. With this, we can match patients to the most appropriate level of postoperative care.

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions.

BACKGROUND: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. METHODS: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. RESULTS: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. CONCLUSION: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.

Outcomes of shoulder arthroplasty following axillary lymph node dissection.

INTRODUCTION: Shoulder arthroplasty with previous axillary lymph node dissection historically has unsatisfactory outcomes. We analyzed outcomes of primary shoulder arthroplasty in patients with previous axillary lymph node dissection. METHODS: Thirty-two primary shoulder arthroplasties after prior axillary lymph node dissection were performed. These patients were analyzed for patient-reported outcomes, range of motion, complications, and reoperations. RESULTS: Average age was 70.8 ± 7.5 years old. There were 19 anatomic total shoulder arthroplasties, four hemiarthroplasties, and nine reverse total shoulder arthroplasties. Eight were performed by a superior approach while 24 were performed by a deltopectoral approach with cephalic vein preservation. There were three complications (one deltoid dehiscence, one axillary nerve palsy, and one postoperative pneumonia). There was one revision (hemiarthroplasty to reverse total shoulder arthroplasty for cuff failure at 91 weeks), two reoperations, and no infections. Patient-reported outcomes were available for 21/26 (80.1%) of the surviving shoulders at 4.8 ± 2.0 years. Average visual analog scale pain score was 7.1 ± 14.5, Simple Shoulder Test score 8.3 ± 2.6 "yes" responses, Single Assessment Numeric Evaluation score 80.2 ± 17.4, and American Shoulder and Elbow Surgeons score 83.6 ± 14.1. CONCLUSION: Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. A deltopectoral exposure can be utilized without substantial risk of worsening lymphedema or wound complications. While a superior approach avoids cephalic vein injury, important approach-related complications (deltoid dehiscence and axillary nerve palsy) were observed.Level of evidence: Level IV-case series.