The impact of elective surgery restrictions during the COVID-19 (coronavirus disease 2019) pandemic on shoulder and elbow surgery: patient perceptions.

BACKGROUND: In late 2019 and early 2020, a novel coronavirus, COVID-19 (coronavirus disease 2019), spread across the world, creating a global pandemic. In the state of Pennsylvania, non-emergent, elective operations were temporarily delayed from proceeding with the normal standard of care. The primary purpose of this study was to determine the proportion of patients who required prescription pain medication during the surgical delay. Secondarily, we sought to determine the proportion of patients who perceived their surgical procedure as non-elective and to evaluate how symptoms were managed during the delay. MATERIALS AND METHODS: A single institutional database was used to retrospectively identify all shoulder and elbow surgical procedures scheduled between March 13 and May 6, 2020. Charts were manually reviewed. Patients who underwent non-shoulder and elbow-related procedures and patients treated by surgeons outside of Pennsylvania were excluded. Patients whose surgical procedures were postponed or canceled were administered a survey evaluating how symptoms were managed and perceptions regarding the delay. Preoperative functional scores were collected. Statistical analysis was performed to determine associations between procedure status, preoperative functional scores, perception of surgery, and requirement for prescription pain medication. RESULTS: A total of 338 patients were scheduled to undergo shoulder and elbow surgery in our practice in Pennsylvania. Surgery was performed as initially scheduled in 89 of these patients (26.3%), whereas surgery was postponed in 179 (71.9%) and canceled in 70 (28.1%). The average delay in surgery was 86.7 days (range, 13-299 days). Responses to the survey were received from 176 patients (70.7%) in whom surgery was postponed or canceled. During the delay, 39 patients (22.2%) required prescription pain medication. The surgical procedure was considered elective in nature by 73 patients (41%). One hundred thirty-seven patients (78%) would have moved forward with surgery if performed safely under appropriate medical guidelines. Lower preoperative American Shoulder and Elbow Surgeons scores (r = -0.36, P < .001) and Single Assessment Numeric Evaluation scores (r = -0.26, P = .016) and higher preoperative visual analog scale scores (r = 0.28, P = .009) were correlated with requiring prescription pain medication. Higher preoperative American Shoulder and Elbow Surgeons scores were positively correlated with perception of surgery as elective (r = 0.4, P < .001). CONCLUSION: Patients undergoing elective shoulder and elbow surgical procedures during the COVID-19 (coronavirus disease 2019) pandemic experienced a delay of nearly 3 months on average. Fewer than half of patients perceived their surgical procedures as elective procedures. Nearly one-quarter of patients surveyed required extra prescription pain medicine during the delay. This study elucidates the fact that although orthopedic shoulder and elbow surgery is generally considered "elective," it is more important to a majority of patients. These findings may also be applicable to future potential mandated surgical care delays by other third-party organizations.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL. METHODS: This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups. RESULTS: Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05). CONCLUSION: Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

A prospective study comparing tendon-to-bone interface healing using an interposition bioresorbable scaffold with a vented anchor for primary rotator cuff repair in sheep.

BACKGROUND: The purpose of this study was to evaluate the biomechanical and histologic properties of rotator cuff repairs using a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA (poly(l-lactide-co-glycoside)) microfibers in an animal model compared to standard anchors in an ovine model. METHODS: Fifty-six (n = 56) skeletally mature sheep were randomly assigned to a repair of an acute infraspinatus tendon detachment using a innovative anchor-PLGA scaffold device (Treatment) or a similar anchor without the scaffold (Control). Animals were humanely euthanized at 7 and 12 weeks post repair. Histologic and biomechanical properties of the repairs were evaluated and compared. RESULTS: The Treatment group had a significantly higher fibroblast count at 7 weeks compared to the Control group. The tendon bone repair distance, percentage perpendicular fibers, new bone formation at the tendon-bone interface, and collagen type III deposition was significantly greater for the Treatment group compared with the Control group at 12 weeks (P ≤ .05). A positive correlation was identified in the Treatment group between increased failure loads at 12 weeks and the following parameters: tendon-bone integration, new bone formation, and collagen type III. No statistically significant differences in biomechanical properties were identified between Treatment and Control Groups (P > .05). CONCLUSIONS: Use of a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA microfibers improves the histologic properties of rotator cuff repairs in a sheep model. Improved histology was correlated with improved final construct strength at the 12-week time point.

Revision of failed hemiarthroplasty and anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty.

BACKGROUND: The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Revision of failed anatomic arthroplasty to reverse total shoulder arthroplasty has shown promise alongside concerning complication rates. METHODS: Patients who underwent revision shoulder arthroplasty during a 7-year period at a tertiary care health system were identified. Presurgical and operative data were analyzed for 110 patients who met inclusion and exclusion criteria. Patients were contacted at a mean follow-up of 57 ± 26 months (range, 23-113 months) from revision surgery for functional outcomes scores, reoperations, and implant survival. RESULTS: Implant survival was 92% at 2 years and 74% at 5 years. Mean American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, and visual analog scale pain scores were 63 ± 24 (range, 5-97), 60 ± 25 (range, 0-100), and 2.9 ± 2.9 (range, 0-10), respectively. Seventy percent of patients were "very satisfied" or "satisfied with their outcome. Complications occurred in 18 patients (20%), and 10 patients (11%) underwent reoperation. CONCLUSIONS: Modest patient results and satisfaction can be achieved with revision of a failed anatomic arthroplasty to a reverse total shoulder arthroplasty. As is typical of revision surgery, complications are common and can compromise results. Further study is needed to identify factors that may contribute to successful outcomes.

Outcomes of an anatomic total shoulder arthroplasty with a contralateral reverse total shoulder arthroplasty.

BACKGROUND: It is common for patients to require staged bilateral shoulder arthroplasties. There is a unique cohort of patients who require an anatomic total shoulder arthroplasty (TSA) and a contralateral reverse shoulder arthroplasty (RSA). This study compared the outcomes of patients with a TSA in 1 shoulder and an RSA in the contralateral shoulder. METHODS: Our institutional database was queried to identify all patients with a TSA and a contralateral RSA. Data collection included patient demographics, preoperative and latest follow-up shoulder range of motion, radiographic analysis, and postoperative complications. Identified patients were assessed at follow-up visits or contacted by phone for functional outcome scores. RESULTS: Nineteen patients met our inclusion/exclusion criteria. There was statistically significant greater internal rotation in the TSA shoulder (P= .044) but no significant difference in forward elevation (P = .573) or external rotation (P= .368). There was no radiographic evidence of humeral or glenoid component loosening of any arthroplasty implants. There were no significant differences between TSA and RSA shoulders for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (P= .381), Simple Shoulder Test (P = .352), Single Assessment Numerical Evaluation (P = .709), and visual analog scale satisfaction (P= .448) or pain scores (P= .305). Thirteen patients (68.4%) preferred the RSA side, 1 patient (5.3%; z = 4.04, P < .001) patient preferred the TSA side, and 5 patients expressed no preference. CONCLUSION: Despite known limitations and differences between TSA and RSA designs, patients who have received both implants are highly satisfied with both. The only parameter in which the TSA had superior outcomes was internal rotation.

Culture positivity in primary total shoulder arthroplasty.

BACKGROUND: The clinical significance of positive cultures in shoulder surgery remains unclear. This study determined the rate and characteristics of positive intraoperative cultures in a cohort of patients undergoing primary shoulder arthroplasty. METHODS: From February 2015 to March 2016, 94 patients, without prior surgery, underwent primary shoulder arthroplasty. Before surgery, all shoulders were prospectively enrolled and consented to obtain standardized intraoperative cultures. All patients received standard preoperative antibiotic prophylaxis. Standardized fluid and tissue locations were sampled and sent for aerobic and anaerobic cultures and held for 13 days. Patients and surgeon were blinded to the culture results. RESULTS: Average age at surgery was 70.5 years (range, 50-91 years), and 41 patients (47%) were male. At least 1 positive culture was found in 33 shoulders (38%), with 17 patients (19%) having ≥2 positive cultures. Cutibacterium (formerly Propionibacterium) acnes was the most common organism (67%), followed by coagulase-negative Staphylococcus (21%), Staphylococcus aureus (3%), and other organisms (18%). The rate of positive culture was higher in men (51%) than in women (26%, P = .016). Cutibacterium acnes was more common in men with positive cultures (95% vs. 17%, P < .001) and coagulase-negative Staphylococcus and Staphylococcus epidermidis were more common in women with positive cultures (42% vs. 10%, P = .071). CONCLUSION: Positive deep tissue cultures develop in a high percentage of patients undergoing primary shoulder arthroplasty despite antibiotic prophylaxis. The long-term clinical implication of this finding requires further study, especially with regard to the risk of late failures of shoulder arthroplasty.

Results of Total Elbow Arthroplasty in Patients Less Than 50 Years Old.

PURPOSE: Total elbow arthroplasty (TEA) is a treatment option for end-stage arthritis in low-demand patients willing to accept the limitations of TEA. Concern remains regarding the longevity of TEA implants, especially in younger patients. The purpose of this study was to determine the failure rate and complication profile of TEA performed in patients aged less than 50 years. METHODS: Between 2009 and 2013, 11 linked TEAs were performed in patients aged less than 50 years (mean age, 37 years; range, 22-47 years). Outcome measures included pain; range of motion; Disabilities of the Arm, Shoulder, and Hand scores; Mayo Elbow Performance scores; complications; and reoperations. Elbows were observed for a minimum of 2 years or until mechanical failure. Mean follow-up was 3.2 years. RESULTS: At follow-up, 82% of TEAs had experienced a complication. Six elbows sustained mechanical failures (5 had ulnar loosening and one had humeral loosening). Pain improved from 8.0 to 4.9. Extension improved from 34° to 22° and flexion increased from 113° to 128°. Mean Disabilities of the Arm, Shoulder, and Hand score for surviving implants at follow-up was 42.9 (range, 17.5-56.7). Mayo Elbow Performance scores for surviving implants were rated as excellent (2), good (1), and fair (2). CONCLUSIONS: High rates of early mechanical failure, predominately ulnar loosening, were observed in TEA in patients aged less than 50 years. Surgeons should remain cautious in performing TEA in young patients who can be expected to use the TEA in a more demanding fashion, placing them at higher risk for mechanical failure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Classifying glenohumeral synovitis: a novel intraoperative scoring system.

BACKGROUND: Synovitis of the shoulder is a common entity that is poorly described. This study aims to create a simple and reliable classification system for glenohumeral synovitis, which would benefit further research related to synovitis and outcomes. METHODS: Twenty 30-second shoulder arthroscopy videos were distributed to 19 fellowship-trained orthopedic surgeons. The observers responded with their years in practice, fellowship type, whether synovitis affects outcomes, and whether synovitis affects plans. The surgeons then rated the videos based on the following: color of capsule (pale, pink, or red); villous projections (none, few, or extensive); capillaries in capsule (scattered or hypertrophied); and axillary recess (normal or contracted). Scores ranging from 0 to 6 were assigned. The videos were randomized and redistributed at a later date. Statistical analysis used an intraclass correlation coefficient with a mixed-effects model to calculate variability based on observer. RESULTS: Nineteen observers completing the survey twice resulted in 760 videos being scored. There were 12 shoulder surgeons and 7 sports surgeons. Only 4 surgeons believed that synovitis did not affect outcomes, and the remaining 15 believed that it did. The intraclass correlation coefficient showed that 68% of the variation in measured scores was due to variation among patients and only 4% was due to variation among observers. There was no significant variation seen in scores due to surgeon experience, surgeon specialty, or first and second viewing. CONCLUSIONS: This interclass observer reliability shoulder synovitis study defined a system with excellent reliability among a range of surgeons with diverse training and experience. In addition, there was excellent reliability for the same surgeon between viewings.

Functional outcomes of distal triceps tendon repair comparing transosseous bone tunnels with suture anchor constructs.

BACKGROUND: Distal triceps tendon ruptures are relatively rare. Few studies have investigated functional outcomes after repair. There is no consensus on fixation methods for this injury. The purpose of this study was to compare the functional outcomes and the reoperation rates after distal triceps tendon repairs using transosseous tunnels and suture anchors. METHODS: A multicenter, retrospective review of all primary triceps repairs done between 2006 and 2015 was performed. Patients were included if they had a minimum of 2 years of follow-up. Intraoperative data recorded included repair method and number of anchors used when applicable. Patients were contacted for functional assessment with the Mayo Elbow Performance Score (MEPS). Postoperative complications were also queried. RESULTS: There were 56 cases of primary triceps repair identified in an all-male cohort. Average age at time of surgery was 52.7 years; 58.9% of patients had transosseous repair, and 41.1% had suture anchor repair. The average follow-up was 4.26 years. The average postoperative MEPS score for all patients was 94. There was no difference in MEPS outcomes based on construct type. Postoperative Disabilities of the Arm, Shoulder, and Hand scores had an overall average of 4.81. A statistically significant difference was found, with the transosseous group averaging 2.98 points lower than the suture anchor group. This difference was not found to be clinically relevant. Only 4 patients had rerupture of the triceps requiring revision. CONCLUSIONS: Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct.

The use of indomethacin in the prevention of postoperative radioulnar synostosis after distal biceps repair.

BACKGROUND: This study evaluated the incidence of symptomatic radioulnar synostosis/heterotopic ossification after distal biceps tendon repair in patients receiving indomethacin prophylaxis. We hypothesized that indomethacin use postoperatively would decrease the occurrence of symptomatic synostosis. METHODS: A single-center retrospective record review identified 124 patients undergoing distal biceps repair between 2011 and 2014. Patients were analyzed for administration of indomethacin, contraindications to administration, age, time to surgery, fixation method, medical comorbidities, and development of symptomatic synostosis. Oral indomethacin (75 mg, once daily) was prescribed postoperatively for 10 to 42 days per each attendings' protocol. RESULTS: After analysis, 112 patients met the inclusion criteria, with 7 undergoing a 1-incision distal biceps repair and 105 undergoing a 2-incision repair. Of those, 104 received indomethacin postoperatively, with a synostosis rate of 0.96% compared with 37.50% for the untreated group (P < .001). No statistically significant difference was found between fixation methods and synostosis. One patient with synostosis was a single-incision repair, and 3 were 2-incision suture bridge repairs. Three patients with synostosis had relative contraindications to administration of indomethacin, including concomitant warfarin use, clopidogrel use, and ulcerative colitis. CONCLUSION: Indomethacin use after distal biceps repair was associated with a statistically significant reduction in the rate of symptomatic radioulnar synostosis and did not have any associated adverse effects, including gastrointestinal bleeding or rerupture, despite prolonged use of up to 6 weeks. This study represents the largest study to report the outcomes of patients undergoing distal biceps repair with concomitant synostosis prophylaxis using indomethacin.

Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with End-stage Shoulder Arthritis.

BACKGROUND: Young patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment. QUESTIONS/PURPOSES: We asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society? METHODS: The incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with "satisfactory" or "excellent" outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States. RESULTS: During the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient). CONCLUSIONS: Treatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old. LEVEL OF EVIDENCE: Level II, economic and decision analysis study.

Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience.

PURPOSE: To report on the intraoperative and early postoperative (<3 months) problems and complications encountered with the arthroscopic Latarjet procedure in patients with complex anterior shoulder instability. METHODS: Between 2010 and 2014, 83 patients underwent an arthroscopic Latarjet procedure for recurrent post-traumatic anterior instability. The group's mean age was 28 ± 10 years and consisted of 76 (92%) male patients. A "problem" was defined as an unanticipated perioperative event that was not likely to affect the patient's final outcome. A "complication" was defined as an event that was likely to negatively affect outcome. RESULTS: At a mean follow-up of 17 months (range, 3 to 43 months), 20 (24%) patients sustained either a problem and/or a complication. The problem rate was 18% and the complication rate was 10%. The most commonly encountered adverse event was intraoperative fracture of the coracoid graft, which occurred in 6 patients (7%). In addition, 1 arthroscopic case was intraoperatively converted to open and 1 patient sustained a transient axillary nerve injury. A total of 7 cases underwent secondary operative procedures. The rate of problems and/or complications in primary cases was not significantly different than revision cases (P = .335). CONCLUSIONS: The rate of adverse events reported in this arthroscopic series is not insignificant and is similar to that reported with the traditional open Latarjet. With appropriate training, the arthroscopic Latarjet procedure can be effective for the management of patients with complex shoulder instability. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Profile of Current Opinion on Arthroscopic Acromioplasty: A Video Survey Study.

PURPOSE: To provide a baseline profile of current opinion on use of arthroscopic acromioplasty and evaluate the consistency of surgical decision making on whether or not to perform acromioplasty across different surgeon practices. METHODS: Twenty-two fellowship-trained orthopaedic shoulder surgeons from the Association of Clinical Elbow and Shoulder Surgeons completed an Internet-based survey on practices associated with acromioplasty, including questions related to 15 arthroscopic videos. Based on video cases, interobserver and intraobserver agreement regarding clinically based decisions related to acromioplasty were assessed. RESULTS: Acromioplasty was uncommonly performed in isolation among this group and was most commonly performed in conjunction with repair of full-thickness rotator cuff tears. Nineteen of 22 (86%) surgeons favored an arthroscopic approach for acromioplasty. Depth of bony resection was determined most commonly based on clinical judgment and experience (68%). The video portion of the survey revealed slight interobserver agreement for classification of acromion morphology (κ = 0.099), need for acromioplasty (κ = 0.020), and adequacy of decompression (κ = 0.1). In contrast, there was fair intraobserver reliability regarding acromion morphology (κ = 0.370) and decision whether to perform acromioplasty in a given case (κ = 0.348) whereas there was moderate intraobserver reliability in the presence of a reparable rotator cuff tear (κ = 0.507) and assessment of the adequacy of decompression (κ = 0.453). CONCLUSIONS: Although surgeons had similarities regarding principles of acromioplasty, including indications, surgical approach, and technique, there was lack of consensus when surgeons reviewed the video of clinical cases. Although surgeons may have similar goals in terms of treatment of pathology related to subacromial impingement, individual surgeon thresholds for the need and adequacy of decompression are varied and are not standardized. LEVEL OF EVIDENCE: Level V, expert opinion.

Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons.

BACKGROUND: This study compared the use of reverse and hemishoulder arthroplasty for the treatment of proximal humeral fractures among orthopedic surgeons taking part II of the American Board of Orthopaedic Surgery board examination. We hypothesized that the use of reverse shoulder arthroplasty for fractures in the elderly is increasing amongst newly trained orthopedic surgeons. MATERIALS AND METHODS: We queried the American Board of Orthopaedic Surgery database for the cases of proximal humeral fractures treated with arthroplasty submitted between 2005 and 2012. We evaluated the prosthesis used, patient-specific factors, complications, and the difference in use by shoulder fellowship-trained surgeons. RESULTS: From 2005 to 2012, 5395 board-eligible orthopedic surgeons submitted cases to the database. Of these, 435 (mean, 54 per year) were proximal humeral fractures treated with arthroplasty. The overall incidence of reverse shoulder arthroplasty for fracture increased from 2% to 4% during 2005 to 2007 to 38% in 2012. Shoulder surgeons treated 5 times more proximal humeral fractures with shoulder arthroplasty and were also more than 20 times more likely to use a reverse implant (P < .0001). The difference in complication rates between reverse and hemishoulder arthroplasty was not significant (P = .49). Patients who received a hemiarthroplasty tended to be younger (mean age, 70.8 vs 75.7 years; P = .0015). CONCLUSIONS: Overall, the use of a hemiarthroplasty for fracture is still more common (62% in 2012), although the relative proportion of reverse implants is rising. Among shoulder surgeons, more than 50% of the arthroplasties performed for fractures during the past 3 years (2010-2012) have been reverse arthroplasties.

Is Arthroscopic Latarjet a Cost-Effective Procedure? A Decision Analysis.

Objectives: Arthroscopic Latarjet for glenohumeral stabilization has emerged as an alternative to the open approach; however, the evidence to date has questioned if this technique delivers improved outcomes. This analysis provides an assessment of the cost and utility associated with arthroscopic versus open Latarjet. Methods: The cost-effectiveness of Latarjet stabilization was modeled over a ten-year period. Institutional cases were reviewed for equipment utilization. Cost data from ambulatory surgical centers was obtained for each piece of equipment used intraoperatively. Based upon prior analyses, the operating room cost was assigned a value of $36.14 per minute. To determine effectiveness, a utility score was derived based upon prior analysis of shoulder stabilization using the EuroQol (EQ) 5D. For reoperations, a utility score of 0.01 was assigned for a single year for revision surgeries for instability and 0.5 for minor procedures. Probability of surgical outcomes and operative time for arthroscopic and open Latarjet were taken from prior studies comparing outcomes of these procedures. Decision-tree analysis utilizing these values was performed. Results: Based upon equipment and operating room costs, arthroscopic Latarjet was found to cost $2,796.87 more than the equivalent open procedure. Analysis of the utility of these procedures were 1.330 and 1.338 quality adjusted life years obtained over the modeled period for arthroscopic versus open Latarjet, respectively. For arthroscopic Latarjet to be cost-equivalent to open Latarjet, surgical time would need to be reduced to 41.5 minutes or the surgical equipment would need to be provided at no expense, while maintaining the same success rates. Conclusion: With nearly identical utility scores favoring open surgery, the added cost associated with arthroscopic Latarjet cannot be supported with available cost and utility data. To provide value, additional benefits such as decreased post-operative narcotic utilization, decreased blood loss, or lower complications of the arthroscopic approach must be demonstrated.

Effects of Patient Comorbidities and Demographics on Episode-of-Care Costs Following Total Shoulder Arthroplasty.

BACKGROUND: As demand for shoulder arthroplasty grows, adequate cost containment is of importance. Given the historical use of bundle payments for lower extremity arthroplasty, it is reasonable to anticipate that such programs will be universally implemented in shoulder arthroplasty. This project evaluates how patient demographics, medical comorbidities, and surgical variables affect episode-of-care costs in an effort to ensure accurate reimbursement scales and equitable access to care. METHODS: Consecutive series of primary total shoulder arthroplasty (anatomic and reverse) procedures were retrospectively reviewed at a single academic institution from 2014 to 2020 using claims cost data from Medicare and a private insurer. Patient demographics, comorbidities, and clinical outcomes were collected. A stepwise multivariate regression was performed to determine the independent effect of comorbidities and demographics on 90-day episode-of-care costs. RESULTS: Overall, 1,452 shoulder arthroplasty patients were identified (1,402 Medicare and 50 private payer patients). The mean 90-day cost for Medicare and private payers was $25,822 and $31,055, respectively. Among Medicare patients, dementia ($3,407, P = 0.003), history of stroke ($3,182, P = 0.005), chronic pulmonary disease ($1,958, P = 0.007), anemia ($1,772, P = 0.039), and heart disease ($1,699, P = 0.014) were associated with significantly increased costs. Demographics that significantly increased costs included advanced age ($199 per year in age, P < 0.001) and elevated body mass index ($183 per point, P < 0.001). Among private payers, hyperlipidemia ($6,254, P = 0.031) and advanced age ($713 per year, P < 0.001) were associated with an increase in total costs. CONCLUSION: Providers should be aware that certain demographic variables and comorbidities (history of stroke, dementia, chronic pulmonary disease, anemia, heart disease, advanced age, and elevated body mass index) are associated with an increase in total costs following primary shoulder arthroplasty. Further study is required to determine whether bundled payment target costs should be adjusted to better compensate for specific comorbidities. LEVEL OF EVIDENCE: Level IV case series.

Predicting Hospital Readmissions After Total Shoulder Arthroplasty Within a Bundled Payment Cohort.

INTRODUCTION: Given the rising demand for shoulder arthroplasty, understanding risk factors associated with unplanned hospital readmission is imperative. No study to date has examined the influence of patient and hospital-specific factors as a predictive model for 90-day readmissions within a bundled payment cohort after primary shoulder arthroplasty. The purpose of this study was to determine predictive factors for 90-day readmissions after primary shoulder arthroplasty within a bundled payment cohort. METHODS: After obtaining IRB approval, a retrospective review of a consecutive series of Medicare patients undergoing primary shoulder arthroplasty from 2014 to 2020 at a single academic institution was conducted. Patient demographic data, surgical variables, medical comorbidity profiles, medical risk scores, and social risk scores were collected. Postoperative variables included length of hospital stay, discharge location, and 90-day readmissions. Multivariate analysis was conducted to determine the independent risk factors of 90-day readmission. RESULTS: Overall, 3.6% of primary shoulder arthroplasty patients (127/3,523) were readmitted within 90 days. Readmitted patients had a longer hospital course (1.75 versus 1.45 P = 0.006), higher comorbidity profile (4.64 versus 4.24 P = 0.001), higher social risk score (7.96 versus 6.9 P = 0.008), and higher medical risk score (10.1 versus 6.96 P < 0.001) and were more likely to require a home health aide or be discharged to an inpatient rehab facility or skilled nursing facility ( P = 0.002). Following multivariate analysis, an elevated medical risk score was associated with an increased risk of readmission (odds ratio = 1.05, P < 0.001). DISCUSSION: This study demonstrates medical risk scores to be an independent risk factor of increased risk of 90-day hospital readmissions after primary shoulder arthroplasty within a bundled payment patient population. Additional incorporation of medical risk scores may be a beneficial adjunct in preoperative prediction for readmission and the potentially higher episode-of-care costs. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Polyethylene wear in retrieved reverse total shoulder components.

BACKGROUND: Reverse total shoulder arthroplasty has been used to treat rotator cuff tear arthropathy and proximal humerus fractures, as well as for failed conventional total shoulder prostheses. It has been suggested that polyethylene wear is potentially higher in reverse shoulder replacements than in conventional shoulder replacements. The modes and degree of polyethylene wear have not been completely elucidated. The purpose of this study was to evaluate polyethylene wear patterns in 7 specimens retrieved at revision arthroplasty and identify factors that may be associated with increased wear. METHODS: Reverse total shoulder components were retrieved from 7 patients during revision arthroplasty for loosening and/or pain. Preoperative glenoid tilt and placement and scapular notching were evaluated by use of preoperative radiographs. Polyethylene wear was evaluated via micro-computed tomography and optical microscopy. RESULTS: Wear on the rim of the polyethylene humeral cup was identified on all retrieved components. The extent of rim wear varied from a penetration depth of 0.1 to 4.7 mm. We could not show a correlation between scapular notching and rim wear. However, rim wear was more extensive when the inferior screw had made contact with the liner. Metal-on-metal wear between the humeral component and the inferior screw of 1 component was also observed. Wear of the intended bearing surface was minimal. DISCUSSION: Rim damage was the predominant cause of polyethylene wear in our retrieved specimens. Direct contact between the humeral component and inferior metaglene screws is concerning because this could lead to accelerated ultra-highmolecular weight polyethylene wear and also induce mechanical loosening of the glenoid component.

Shoulder Synovitis Does not Affect Pain After Arthroscopic Rotator Cuff Repair.

Background: The goal of this study was to determine if there is an association between glenohumeral synovitis and early post-operative pain after arthroscopic rotator cuff repair. Methods: Fifty patients with symptomatic rotator cuff tears were prospectively enrolled prior to RCR. Baseline ASES score, VAS Pain score, forward elevation, and external rotation were recorded. Intra-operatively, synovitis was graded on a scale of zero to six as based on a previously validated scoring system. VAS Pain scores were obtained from patients post-operatively on days one through 14, week 6, and 3 months. Results: Average intra-operative synovitis score was 2.4 ± 1.6. No significant correlation was found between synovitis score and pre-operative forward elevation (P=0.171), external rotation (P=0.126), VAS Pain (P=0.623), or ASES (P=0.187) scores. No significant correlation was found between synovitis score and post-operative VAS Pain level at any time point. There was a moderate correlation between both pre-operative VAS Pain and ASES scores and post-operative VAS Pain in the first post-operative week. Workers' compensation patients had worse pain at 3 months post-operatively compared to non-workers compensation patients (P=0.038). Conclusion: This study reveals that macroscopically assessed glenohumeral synovitis does not have any significant correlation with pre-operative or post-operative pain in patients undergoing arthroscopic rotator cuff repair; although higher pre-operative pain levels, worse pre-operative ASES scores, and workers compensation status do influence post-operative pain levels in arthroscopic rotator cuff repair.

The recurrent unstable elbow: diagnosis and treatment.

The elbow is a difficult joint to treat because of the subtle nuances involved in pathology, examination, and treatment. Patients experiencing the sequelae of recurrent elbow instability can lose substantial function in the affected upper extremity. Elbow instability comprises a wide spectrum of diseases, ranging from valgus instability in the throwing athlete to traumatic recurrent rotatory instability to iatrogenic damage. For the orthopaedic surgeon to develop a systematic algorithm for treating elbow instability disorders, it is necessary to understand the basic elbow biomechanics and the alterations that occur in the unstable elbow. A thorough knowledge of the history, physical examination techniques, and imaging studies necessary to diagnose these injury patterns is also needed. Cutting-edge advances in the surgical reconstruction of the unstable elbow will allow those caring for patients with these difficult injuries to make the proper management decisions.