Treatment of race and ethnicity in shoulder and elbow research: An analysis of the most cited papers on rotator cuff repair.

Background: This study examined the current approach to the inclusion of race and ethnicity among frequently referenced shoulder surgery literature and discussed guidance for best practices for the inclusion of race and ethnicity in shoulder research. Methods: The shoulder literature were systematically reviewed for the most frequently cited studies discussing rotator cuff repair, total shoulder arthroplasty, and Bankart repair. All reviewed studies met the timeline criteria (2013-2022). Only studies with clinical outcomes were included. Review articles, meta-analyses, systematic reviews, basic science studies, or any manuscript that did not represent clinical outcomes research were excluded. Author, year issued, the journal in which the paper was published, study design, the number of subjects, duration of follow-up, independent variables, dependent variables, results, and conclusions were extracted from the articles that met the inclusion criteria. Whether race and/or ethnicity were included in the study design in any way was also recorded. For those studies in which race and ethnicity were included, a detailed analysis of the paper's treatment of race using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals was performed and recorded. Results: In the "rotator cuff repair" cohort of papers, there were 2 articles that mention race. Out of the 2 articles that mentioned race, neither included race appropriately using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals. In the "Bankart repair" cohort of papers, each article lacked the mention of race among their patient population. The "total shoulder arthroplasty" manuscripts also did not include treatment of race and ethnicity in any way. Discussion: Race and ethnicity and other social determinants of health can be used to understand the source of healthcare disparities. Unless a thoughtful and deliberate consideration of race and ethnicity is undertaken, their inclusion in clinical research can be a double-edged sword due to the potential race and ethnicity-centered treatment involvement can be rooted in fallacies. In shoulder surgery clinical research, race and ethnicity should be considered in concert with social factors that could exacerbate poor patient outcomes in our patient population. Level of evidence: Level V.

Arthroscopic Visualization Is a Reliable Method of Confirming Femoral Button Placement During Anterior Cruciate Ligament Reconstruction.

Purpose: To compare arthroscopic visualization with intraoperative fluoroscopy for confirming proper femoral button placement during ACLR. Methods: Fifty consecutive patients undergoing soft-tissue ACLR between March 2021 and February 2022 were evaluated for inclusion in this study. Both primary and revision ACLR cases using suspensory fixation were included. Surgeons rated their confidence of proper button placement from both an intra-articular perspective (through the femoral tunnel) and an extra-articular perspective (through the iliotibial band) by grading confidence with a Likert scale. Fluoroscopy was also performed for confirmation of proper button placement. Results: Fifty consecutive patients (35.1 ± 14.5 years of age) with soft-tissue ACLR were included. Mean surgeon Likert confidence scores for accurate button placement were as follows: 4.1 of 5 ± 0.9 from an intra-articular perspective, 4.6 of 5 ± 0.7 from an extra-articular perspective, and 8.7 of 10 ± 1.4 based on the sum of intra- and extra-articular perspectives. Fluoroscopic findings demonstrated that 48 of 50 cases had an appropriate flipped button on the lateral cortex of the femur. I total, 2 of 50 had soft-tissue interposition. Cases in which surgeons had high confidence from both intra- and extra-articular perspectives (≥9/10 sum score) were indicative of proper button placement 97% of the time. Conclusions: Arthroscopic visualization is a reliable method of confirming femoral button placement during ACLR and is sufficient to rule out intraoperative fluoroscopy during surgery. ACLR cases with high surgeon confidence from both intra- and extra-articular perspectives (sum score of 9 or greater out of 10) resulted in proper femoral button placement in 97% of cases as confirmed by intraoperative fluoroscopy. Level of Evidence: Level II, prospective cohort study.

Opioid Requirement After Anterior Cruciate Ligament Surgery: Opioid Use After Anterior Cruciate Ligament Surgery Is Low With a Multimodal Approach, and Fifteen Oxycodone 5-mg Tablets Are Sufficient.

Purpose: To prospectively determine opioid consumption in patients undergoing anterior cruciate ligament (ACL) repair and reconstruction and to develop evidence-based prescription guidelines following ACL surgery. Methods: This multicenter prospective study enrolled patients undergoing ACL reconstruction and repair. Subject demographics and opioid prescriptions were recorded at enrollment. All patients were given education on opiate use and followed the same perioperative, multimodal analgesic regimen. Following surgery, patients were given postoperative "pain journals" to document visual analog scale pain scores and daily opioid consumption for the first 7 postoperative days and on postoperative visit at 14 days. Results: In total, 50 patients were included in this analysis between the ages of 14 and 65 years. Patients were prescribed a median of 15 oxycodone 5-mg pills and consumed a median of 2 pill postoperatively (range 0-19 pills). 38% of patients consumed 0 opioid pills, 74% of patients consumed ≤5 opioid pills, and 96% of patients consumed ≤15 opioid pills. Patients reported a mean daily visual analog scale value of 2.8 of 10; mean satisfaction with pain management was high at 4.1/5 on a Likert satisfaction score. Overall, patients consumed a mean 34% of their opioid prescriptions, leaving 436 opioid pills not consumed. Conclusions: This study suggests that current expert panels may be recommending an excessive volume of opioids. Based on our findings, we recommend that patients be prescribed no more than 15 Oxycodone 5-mg tablets following ACL surgery. Despite this lower volume prescription, mean pain scores remained below 3 of 10, patient satisfaction with pain control remained high, and 66% of opiate medication prescribed was not used. Level of Evidence: II, prospective prognostic cohort investigation.

Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial.

BACKGROUND: The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair. METHODS: Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant. RESULTS: Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745. CONCLUSION: Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.

Opioid Consumption After Knee Arthroscopy.

PURPOSE: To prospectively observe opioid consumption in patients undergoing knee arthroscopy and to create an evidence-based guideline for opioid prescription. METHODS: This prospective multicenter observational study enrolled patients undergoing outpatient knee arthroscopy for meniscal repair, meniscectomy, or chondroplasty. Patients were provided with a pain journal to record postoperative opioid consumption, Numeric Pain Rating Scale (NPRS) pain scores, and Likert scale satisfaction scores for 1 week postoperatively. State databases were reviewed for additional opioid prescriptions. RESULTS: One hundred patients were included in this study. Patients were prescribed a median of 5 pills (37.5 oral morphine equivalent [OME]). Median postoperative opioid consumption was 0 pills, with a mean of 0.6 pills (4.4 OME), and 74% of patients did not consume any opioid medication postoperatively. All patients consumed ≤5 pills (37.5 OME), and no patient required a refill. Patients reported a mean daily NPRS value of 1.9 out of 10 and a mean Likert score of 4.4 out of 5. CONCLUSION: We found that current opioid prescribing habits exceed the need for postoperative pain management. Overall, all patients consumed ≤5 opioid pills, and 92% of patients discontinued opioids by the second postoperative day. In spite of the low prescription quantity, patients reported high satisfaction rates and low NPRS pain scores and required no refills. Therefore, we recommend that patients undergoing knee arthroscopy are prescribed no more than 5 oxycodone 5-mg pills. LEVEL OF EVIDENCE: II, prospective prognostic cohort investigation.

The relationship between scapular notching and reverse shoulder arthroplasty prosthesis design.

BACKGROUND: Inferior scapular notching is a common radiographic complication of reverse shoulder arthroplasty. The purpose of this study is to determine the impact of prosthesis design on the incidence and severity of notching. MATERIALS AND METHODS: Eighty-eight patients (mean age, 72 years) who underwent reverse shoulder arthroplasty with a minimum of 12 months' follow-up (mean, 31 months) were retrospectively reviewed. Patients were grouped based on prosthesis design: Tornier (Stafford, TX, USA) (45%), Zimmer (Warsaw, IN, USA) with a nonretentive liner (35%), and Zimmer with a retentive liner (19%). Notching on final radiographs was graded by use of the Sirveaux classification system and a novel classification system. RESULTS: The incidence of notching was significantly higher with the Tornier prosthesis (92%) compared with the Zimmer prosthesis with nonretentive liners (58%) and retentive liners (71%) (P < .05). The incidence of high-grade notching and the median grade were significantly higher with the Tornier prosthesis compared with the Zimmer prosthesis (P < .05). By use of the novel grading system, there was a higher incidence of notching involving the baseplate with the Tornier prosthesis (68%) compared with the Zimmer prosthesis (33%) (P < .05). The addition of a retentive liner was not associated with greater notching than a nonretentive liner for the Zimmer implant. Diagnosis had no significant influence on notching. CONCLUSIONS: A higher incidence and severity of notching were observed with the Tornier reverse arthroplasty compared with the Zimmer reverse arthroplasty at short-term follow-up. These findings may be because of the different morphology of the polyethylene component and/or differences in glenosphere offset between the prosthetic systems. In addition to surgical technique, consideration should be given to prosthesis design in mitigating the risk of scapular notching.

Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome: surgical technique.

BACKGROUND: Literature regarding the outcomes of revision rotator cuff repair is limited. The purposes of the present study were to report the tendon repair integrity and clinical outcomes for a cohort of patients following revision arthroscopic rotator cuff repair and to examine factors related to tendon healing and the influence of healing on clinical outcomes. METHODS: Twenty-one of twenty-nine consecutive revision arthroscopic rotator cuff repairs with a minimum of two years of postoperative follow-up were retrospectively reviewed. Outcomes were evaluated on the basis of a visual analog pain scale, the range of motion of the shoulder, the Simple Shoulder Test, the American Shoulder and Elbow Surgeons score, and the Constant score. Ultrasonography was used to examine repair integrity at a minimum of one year following surgery. Ten shoulders underwent arthroscopic repair of a recurrent single-tendon posterior rotator cuff tear, whereas eleven shoulders had repair of both the supraspinatus and infraspinatus. RESULTS: The mean age of the twenty-one subjects was 55.6 years; thirteen subjects were male and eight were female. Complete preoperative and postoperative clinical data were available for nineteen subjects after an average duration of follow-up of thirty-three months. Significant improvements were seen in terms of postoperative pain (p < 0.05), the Simple Shoulder Test score (p < 0.05), the American Shoulder and Elbow Surgeons function (p < 0.05) and total scores (p < 0.05), active forward elevation (p < 0.05), and active external rotation (p < 0.05). Postoperative ultrasound data were available for all twenty-one shoulders after a mean duration of follow-up of twenty-five months. Ten (48%) of the twenty-one shoulders had an intact repair. Seven (70%) of the ten single-tendon repairs were intact, compared with three (27%) of the eleven supraspinatus/infraspinatus repairs (p = 0.05). Patient age (p < 0.05) and the number of torn tendons (p = 0.05) had significant effects on postoperative tendon repair integrity. Shoulders with an intact repair had better postoperative Constant scores (p < 0.05) and scapular plane elevation strength (p < 0.05) in comparison with those with a recurrent tear. CONCLUSIONS: Revision arthroscopic rotator cuff repair results in reliable pain relief and improvement in shoulder function in selected cases. Approximately half of the revision repairs can be expected to be intact at a minimum of one year following surgery. Patient age and the number of torn tendons are related to postoperative tendon integrity. The postoperative integrity of the rotator cuff can have a significant influence on shoulder abduction strength and the Constant score.

The effect of distal clavicle excision on in situ graft forces in coracoclavicular ligament reconstruction.

BACKGROUND: Recently, some have suggested that the acromioclavicular articulation confers stability to the construct after coracoclavicular ligament reconstruction for acromioclavicular joint separation. Therefore, it has been suggested that distal clavicle excision should not be performed in this context to protect the graft during healing. HYPOTHESIS: Sectioning the acromioclavicular ligaments would significantly increase in situ forces of a coracoclavicular ligament graft, whereas performing a distal clavicle resection would not further increase in situ graft forces. DESIGN: Controlled laboratory study. METHODS: A simulated coracoclavicular reconstruction was performed on 5 cadaveric shoulders. Static loads of 80 N and 210 N were applied directly to the clavicle in 5 directions: anterior, anterosuperior, superior, posterosuperior, and posterior. The in situ graft force was measured using a force transducer under 3 testing conditions: (1) intact acromioclavicular ligaments, (2) sectioned acromioclavicular ligaments, and (3) distal clavicle excision. RESULTS: For both magnitudes of load, in all directions, in situ graft force with intact acromioclavicular ligaments was significantly less than that with sectioned acromioclavicular ligaments (P < .001). Distal clavicle excision did not further increase the in situ graft forces with load applied to the clavicle in an anterior, anterosuperior, or superior direction. However, in situ graft forces were increased with distal clavicle excision when the clavicle was loaded with 210 N in the posterosuperior direction (60.4 ± 6.3 N vs 52.5 ± 7.1 N; P = .048) and tended to be increased with posterior loading of the clavicle (71.8 ± 6.2 N vs 53.1 ± 8.8 N; P = .125). CONCLUSION: Intact acromioclavicular ligaments protect the coracoclavicular reconstruction by decreasing the in situ graft force. The slight increase in the in situ graft force only in the posterosuperior and posterior direction after distal clavicle excision suggests only a marginal protective role of the acromioclavicular articulation. Further, the peak graft forces observed represent only a small fraction of the ultimate failure strength of the graft. CLINICAL RELEVANCE: Distal clavicle excision can perhaps be safely performed in the context of coracoclavicular ligament reconstruction without subjecting the graft to detrimental in situ force. Although the acromioclavicular articulation serves only a marginal role in protecting the coracoclavicular ligament graft, reconstruction of the acromioclavicular ligaments may serve an important role in decreasing in situ graft force during healing.

Evaluation of suture abrasion against rotator cuff tendon and proximal humerus bone.

PURPOSE: This study evaluates the abrasion properties of different suture materials through the rotator cuff tendon and proximal humerus tuberosity bone. METHODS: Three types of sutures were compared: monofilament polypropylene, braided polyester, and braided polyblend polyester with a polyethylene core. For soft-tissue testing, the suture was passed through the infraspinatus tendons of 11 cadaveric shoulders. The suture was cycled with a fixed load, and the migration of the suture as it cut through the tissue was measured at intervals of 5 cycles, for a total of 50 cycles. For tuberosity testing, the sutures were passed through a transosseous tunnel created in the lesser tuberosity, and the suture was cycled with a fixed load until suture failure occurred. RESULTS: On soft-tissue testing, the monofilament suture showed the least amount of abrasion, followed by the braided polyblend and then the braided polyester suture (cutting rate of 0.06 +/- 0.11 mm/cycle, 0.99 +/- 0.44 mm/cycle, and 1.75 +/- 0.91 mm/cycle, respectively; P < .0001). On tuberosity testing, suture breakage for the braided polyblend suture occurred at 501.3 +/- 220.4 cycles. The braided polyester and monofilament sutures broke after 256.6 +/- 120.9 and 193.5 +/- 144.8 cycles, respectively. The difference between cycles to failure of the polyblend and latter 2 sutures was statistically significant (P < .0001). CONCLUSIONS: This study shows increased abrasion properties for braided sutures compared with monofilament sutures, as well as different abrasion properties among different types of braided sutures. Furthermore, the braided polyblend suture showed significantly increased cycles before suture failure through a transosseous tunnel. CLINICAL RELEVANCE: Although development of new suture materials has increased their failure strength, further advancements in suture material design should focus on decreasing soft-tissue abrasion properties and increasing strength to suture failure when cycled through bone.