Rotator cuff tears.

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

The role of body mass index on survivorship and clinical outcomes in total shoulder arthroplasty.

BACKGROUND: Increased body mass index (BMI) is a potential risk factor for poorer outcomes and complications. However, the influence of BMI on the long-term outcomes of anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) remains to be fully elucidated. METHODS: Institutional records were queried to identify patients who underwent primary TSA between 2009-2020 with a minimum of 2 years of clinical follow-up. Retrospective review was performed to collect demographics, comorbidity status, and range of motion and strength measurements in forward elevation, external rotation, and internal rotation. Patients were called to obtain patient reported outcomes. Patients were stratified into 3 cohorts, by BMI: underweight or normal weight (U/NW, BMI≤25), overweight (OW, 2530). RESULTS: Among 466 TSA patients, 245 underwent aTSA while 221 underwent rTSA. In the aTSA cohort, 40 were classified as U/NW, 72 as OW, and 133 as obese. Comparatively, the rTSA cohort was composed of 33 U/NW, 79 OW, and 209 obese patients. aTSA and rTSA patients had an average follow-up of 5.8±3.2 years and 4.5±2.3 years, respectively. No differences were found in age at surgery for the aTSA group (U/NW: 65.2±7.9 vs obese: 61.9±8.9 years; p=0.133), however, in the rTSA cohort, BMI was found to be inversely related to age at surgery (U/NW: 72.4±8.8 vs obese: 65.7±8.3 years; p<0.001). Across all BMI cohorts, patients saw great improvement in range of motion and strength. Postoperative patient reported outcomes for TSA did not vary by BMI in SANE, SST, VAS pain, and ASES scores. There was no significant difference in survival rates at 10-year follow-up in aTSA (U/NW: 95.8% vs obese: 93.2%; p=0.753) or rTSA (U/NW: 94.7% vs obese: 94.5%; p=0.791). CONCLUSION: With dramatic improvements in range of motion, minimal differences in patient reported outcomes, and high rates of implant survival, TSA is a safe and effective treatment option for all patients, including for overweight and obese patients.

Posterior Glenoid Bone Block Reconstruction: Indications, Techniques, and Outcomes.

Posterior shoulder instability is of particular therapeutic interest, as it typically affects patients with high functional demands such as young athletes and active adults. Although posterior capsulolabral repair has high return-to-sport rates, it is associated with recurrent instability of up to 11%. Posterior glenoid bone loss and significant glenoid retroversion have been identified as risk factors for recurrent instability and failure after primary arthroscopic soft-tissue repair. Therefore, posterior glenoid bone block reconstruction may be indicated for glenoid bone loss 20% or greater (as measured by the perfect circle technique) or greater than 10% in the setting of pathologic glenoid, failed primary posterior labral repair, incompetent posterior capsular tissue, or significant risk factors for failure of soft-tissue repair. This procedure may be performed arthroscopically or with a posterior open approach using distal tibial allograft, iliac crest autograft, or scapular spine autograft. Although short-term to midterm outcomes have been promising, there remain concerns regarding long-term outcomes, with potentially high rates of late recurrence, revision, and secondary osteoarthritis.

Psychological Factors That Affect Return to Sport After Surgical Intervention for Shoulder Instability: A Systematic Review.

Background: Recent advances have begun to identify the nonphysical factors facilitating successful return to sport (RTS) after shoulder instability surgery, yet little is currently known regarding psychological factors and RTS. Purpose/Hypothesis: The purposes of this study were to (1) identify psychological factors associated with RTS, (2) evaluate the prognostic utility of various psychological factors, and (3) evaluate the available metrics used to assess psychological RTS readiness. It was hypothesized that psychological factors would be identified as critical elements influencing a patient's RTS. Study Design: Systematic review; Level of evidence, 4. Methods: Clinical studies reporting on the psychological determinants of RTS for patients who had surgery for shoulder instability between 1996 and 2022 were identified from MEDLINE, Embase, and Cochrane databases. Demographic, clinical, and psychometric properties were extracted for pooled weighted analysis. Results: Of the 969 studies screened, 24 (2.5%) met inclusion criteria. Overall, 2135 patients were included (mean age, 26.0 years; range, 17.4-35.5 years; 84.7% male). The mean time to RTS was 6.8 months (range, 3.7-11.9 months). There was a 76.3% rate of any RTS; of the 1212 patients who reported level of play at return, 305 (25.2%) were unable to perform at their prior level. Psychological reasons were cited by 85% (n = 360) of patients who did not RTS. Fear of reinjury was the most common reason (n = 154; 42.8%); other psychological factors included lack of confidence (n = 46; 12.8%), anxiety (n = 45; 12.5%), depression (n = 44; 12.2%), psychosocial factors (n = 48; 13.3%), and lack of motivation (n = 23; 6.4%). The Shoulder Instability Return to Sport after Injury, Western Ontario Shoulder Instability Index, Quick Inventory of Depressive Symptoms Self Report, Degree of Shoulder Involvement in Sports, Tampa Scale of Kinesiophobia-11, and Veterans Rand 12-Item Health Survey were reported measures for assessing psychology and RTS. Conclusion: Fear of reinjury was found to be the most commonly reported impediment to RTS. The psychological characteristics identified through this review may be incorporated into future RTS protocols seeking to address resilience and nonphysical factors associated with RTS.

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Development and Validation of a Short-Form Version of the Western Ontario Shoulder Instability Scale (Short-WOSI).

BACKGROUND: Patient-reported outcome measures (PROMs) have transitioned from primarily being used as research instruments to becoming increasingly used in the clinical setting to assess recovery and inform shared decision-making. However, there is a need to develop validated short-form PROM instruments to decrease patient burden and ease incorporation into clinical practice. PURPOSE: To assess the validity and responsiveness of a shortened version of the Western Ontario Shoulder Instability Index (Short-WOSI) when compared with the full WOSI and other shoulder-related PROM instruments. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: This study was a secondary analysis of data collected as part of an institutional review board-approved, multicenter cohort of 1160 patients undergoing surgical stabilization for shoulder instability. The following PROMs were captured preoperatively and 2 years after surgery: WOSI, American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and 36-Item Health Survey (RAND-36). The cohort was split into 2 data sets: a training set to be used in the development of the Short-WOSI (n = 580) and a test set to be used to assess the validity and responsiveness of the Short-WOSI relative to the full WOSI, ASES, SANE, and RAND-36. RESULTS: The Short-WOSI demonstrated excellent internal consistency before surgery (Cronbach α = .83) and excellent internal consistency at the 2-year follow-up (Cronbach α = .93). The baseline, 2-year, and pre- to postoperative changes in Short-WOSI and WOSI were closely correlated (r > 0.90), with both demonstrating large effect sizes (Short-WOSI = 1.92, WOSI = 1.81). Neither the Short-WOSI nor the WOSI correlated well with the other PROM instruments before (r = 0.21-0.33) or after (r = 0.25-0.38) surgery. The Short-WOSI, WOSI, and SANE scores were more responsive than ASES and RAND-36 scores. CONCLUSION: The 7-item Short-WOSI demonstrated excellent internal consistency and a lack of floor or ceiling effects. The Short-WOSI demonstrated excellent cross-sectional and longitudinal construct validity and was similarly responsive over time as the full WOSI. Neither the Short-WOSI nor WOSI correlated with more general shoulder PROMs, underscoring the advantage of using instability-specific instruments for this population.

Modern Applications of Machine Learning in Shoulder Arthroplasty: A Review.

¼ There is increased integration of machine learning (ML) to aid clinical decision-making in orthopaedic surgery.¼ ML has the ability to predict both clinical outcomes such as range of motion and complications in total shoulder arthroplasty patients.¼ An increased area of focus is the ability for ML to identify implants to aid in revision surgery planning.¼ In this article, we review the current applications of ML in shoulder arthroplasty and discuss future areas where it may enhance orthopaedic practice.

Predictors of Bone Loss in Anterior Glenohumeral Instability.

BACKGROUND: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. RESULTS: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. CONCLUSION: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. REGISTRATION: NCT02075775 (ClinicalTrials.gov identifier).

Shoulder arthroplasty following solid organ transplant: A systematic review and meta-analysis.

Introduction: The purpose of this study is to report a systematic review and meta-analysis of solid organ transplant (SOT) patients undergoing shoulder arthroplasty to compare functional and radiographic outcomes, demographics, and complications with non-transplant patients. Methods: Studies were included if they examined patients undergoing shoulder arthroplasty in the setting of prior solid organ transplantation and included post operative range of motion, patient-reported outcomes, complications, or revisions. Studies were excluded if they were national database analyses or lacked clinical data. Pubmed, MEDLine, Scopus, and Web of Science were queried using relevant search terms in July 2022. Data was pooled, weighted, and a paired t-test and chi-square analysis was performed. Results: There were 71 SOT and 159 non-SOT shoulders included in the study. The most common indication for surgery was avascular necrosis (n = 26) in the solid organ transplant group and osteoarthritis (n = 60) in the non-SOT group. Forward elevation, external rotation, ASES, and VAS pain scores improved significantly in both cohorts following surgery. There was no significant difference in age at surgery (p-value = 0.20), postoperative forward elevation (p-value = 0.08), postoperative external rotation (0.84), and postoperative ASES scores (p-value = 0.11) between the two cohorts. VAS pain scores were significantly lower in the SOT cohort (p-value<0.01). The risk of death was significantly higher in the SOT group (p-value<0.01). but the rate of overall complications (p = 0.47), surgical complication (p-value = 0.79), or revision surgery (p-value = 1.00) was not significantly different between the two cohorts. Conclusion: Shoulder arthroplasty is a safe, effective option in patients following solid organ transplant. There is not an increased risk of adverse outcomes, and SOT patients had comparable range of motion and patient-reported outcomes when compared to their non-SOT peers. Level of evidence: III.

Factors Associated With Shoulder Activity Level at Time of Surgery and at 2-Year Follow-up in Patients Undergoing Shoulder Stabilization Surgery.

BACKGROUND: Patients undergoing shoulder stabilization surgery have been shown to have elevated activity levels. Factors associated with shoulder activity in this patient population at baseline and after surgery are unknown. HYPOTHESIS: Patient-specific variables are associated with shoulder activity level at baseline and at 2-year follow-up in a cohort of patients undergoing shoulder stabilization surgery. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing shoulder stabilization surgery were prospectively enrolled. As part of the data collection process, patients completed a previously validated Shoulder Activity Scale. A regression analysis was performed to assess the association of patient characteristics with baseline and 2-year follow-up shoulder activity levels. RESULTS: A total of 764 (n = 612 men, n = 152 women) out of 957 patients (80%) undergoing shoulder stabilization surgery with a median age of 25 years had baseline and 2-year follow-up data and were included in the current analysis. The baseline shoulder activity level was associated with race ( P < .0001) and preoperative duration of instability (P < .0001). At 2 years, 52% of the cohort had returned to the same or higher activity level after surgery. Predictors of higher shoulder activity level at 2-year follow-up included higher baseline activity level (P < .0001), male sex (P < .0001), younger age (P = .004), higher body mass index (BMI) (P = .03), more dislocations (P = .03), nonsmokers (P = .04), and race (P = .04). CONCLUSION: A longer duration of preoperative symptoms was associated with a lower baseline activity in this cohort. High baseline preoperative shoulder activity, younger age, male sex, higher BMI, number of dislocations, and nonsmoking status predicted higher shoulder activity 2 years after shoulder stabilization surgery. REGISTRATION: NCT02075775 (ClinicalTrials.gov identifier).

Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty.

Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency.

PURPOSE: We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes. METHODS: Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected. RESULTS: The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present. CONCLUSION: Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes. LEVEL OF EVIDENCE: IV, retrospective cohort.

Editorial Commentary: Lower Return to Play After Failed Prior Instability Surgery: Should the Open Latarjet Be the Gold Standard for Anterior Shoulder Instability?

Anterior shoulder instability is common in contact athletes. Arthroscopic Bankart repair can result in good clinical outcomes, but high recurrence rates have been reported. The open Latarjet procedure can result in excellent functional outcomes with low rates of recurrent instability. Despite these encouraging results, there may be a lower return to play rate in athletes undergoing this procedure for a prior failed instability surgery. Due to the complexity of the procedure and high complication rate, the open Latarjet should continue to be reserved for cases of significant glenoid bone loss or revision settings.

The Effect of Patient and Surgical Factors on Opioid Prescription Requests Following Arthroscopic Rotator Cuff Repair.

PURPOSE: To determine whether differences in total morphine equivalent doses (MEDs) prescribed after arthroscopic rotator cuff repair (RCR) existed because of age younger than or older than 55 years and sex and to characterize potential risk factors for needing an opioid medication refill, visiting a provider other than the surgeon (either in the emergency department or ambulatory settings), and postoperative pain control requiring opioids approximately 6 weeks from the date of surgery. METHODS: A retrospective cohort study of 100 patients who underwent arthroscopic RCR between July 1, 2018, to November 30, 2018, in a single institution was performed. Data including demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Our primary hypotheses were evaluated with the Wilcoxon-Mann-Whitney test. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values. RESULTS: There was a difference (P = .038) in total MEDs used (in 5 mg oxycodone tablets) between males (median 56 tablets; interquartile range, 50-98 tablets) and females (median 78 tablets; interquartile range, 56-116 tablets). Age younger than 55 years was a risk factor for seeking an opioid refill (OR = 2.51; CI, 1.11-5.66; P = .026). A significant risk factor for visiting another provider was preoperative opiate use (OR = 15.0; CI, 1.79-125.8; P = .013). Age younger than than 55 years (aOR = 2.51; CI, 1.01-6.02; P = .047), body mass index (aOR = 1.08; CI, 1.01-1.17; P = .046), and shorter surgical duration (aOR = 0.97; CI, 0.95-0.99, P =.007) were independent predictive factors for requiring opioids for pain control 6 weeks after surgery. CONCLUSIONS: After arthroscopic RCR, MED prescription is higher for females than males. The risk factors for requesting opioid prescription refill for pain control 6 weeks after surgery were age younger than 55 years and shorter surgical duration. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Outpatient Total Shoulder Arthroplasty: A Systematic Review Evaluating Outcomes and Cost-Effectiveness.

BACKGROUND: Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA. METHODS: A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate. RESULTS: Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age. CONCLUSIONS: Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Beach Chair Versus Lateral Decubitus Position: Differences in Suture Anchor Position and Number During Arthroscopic Anterior Shoulder Stabilization.

BACKGROUND: Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o'clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions. HYPOTHESIS: Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o'clock position. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This study was a cross-sectional analysis of a prospective multicenter cohort of patients undergoing primary arthroscopic anterior capsulolabral repair. Patient positioning in the BC versus LD position was determined by the operating surgeon and was not randomized. At the time of operative intervention, surgeon-reported labral tear length, total anchor number, anchor number in the inferior glenoid, and anchor placement at the 6-o'clock position were evaluated between BC and LD cohorts. Descriptive statistics and between-group differences (continuous: t test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed. RESULTS: In total, 714 patients underwent arthroscopic anterior capsulolabral repair (BC vs LD, 406 [56.9%] vs 308 [43.1%]). The surgeon-reported labral tear length was greater for patients having surgery in the LD position (BC vs LD [mean ± SD], 123.5°± 49° vs 132.3°± 44°; P = .012). The LD position was associated with more anchors placed in the inferior glenoid and more frequent placement of anchors at the 6-o'clock (BC vs LD, 22.4% vs 51.6%; P < .001). The LD position was more frequently associated with utilization of ≥4 total anchors (BC vs LD, 33.5% vs 46.1%; P < .001). CONCLUSION: Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o'clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o'clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study. REGISTRATION: NCT02075775 (ClinicalTrials.gov identifier).

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

The utility and cost of atypical cultures in revision shoulder arthroplasty.

BACKGROUND: At the time of revision shoulder arthroplasty, it is common practice to take cultures to evaluate for prosthetic joint infection even when an alternative cause of failure has been identified. Although isolation of fungal or acid-fast organisms is rare, it remains common practice to send all specimens for aerobic, anaerobic, and atypical (fungal and acid-fast) cultures. We hypothesize that the rate of positive atypical cultures at the time of revision shoulder arthroplasty is very low and routine use imposes a considerable financial burden on the health care system. METHODS: A retrospective review of all revision shoulder arthroplasties performed between January 1, 2010, and December 31, 2019, at our institution was performed. Patients with a hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, or pre-existing antibiotic spacer who underwent revision to hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, antibiotic spacer, or resection arthroplasty were included. Electronic patient charts were reviewed to gather patient, surgical, and culture data. An analysis of the hospital billing charges associated with each culture was performed using our hospital billing database and the current procedural terminology (CPT) codes for aerobic, anaerobic, fungal, and acid-fast cultures. A secondary outcome analysis was performed to identify factors associated with positive cultures. RESULTS: A total of 237 revision shoulder arthroplasties performed on 189 patients were analyzed. Cultures were sent on 158 of 237 (66.7%) surgeries with an average of 2.2 specimens per surgery. A total of 341 aerobic, 331 anaerobic, 187 fungal, and 174 acid-fast cultures were collected. Positive cultures were found in 52 of 341 (15.2%) aerobic cultures and 36 of 331 (10.9%) anaerobic cultures. The most commonly isolated organism was Cutibacterium acnes (42.2%), followed by methicillin-resistant Staphylococcus aureus (15.6%), coagulase-negative Staphylococcus species (13.3%), and methicillin-sensitive S. aureus (12.2%). There were zero positive fungal or acid-fast cultures in our series. The total billing charges for aerobic, anaerobic, fungal, and acid-fast cultures over the study period were $77,748, $23,832, $8,789, and $106,662, respectively, with atypical cultures accounting for 53.2% of the total charges for all cultures. For a single sample sent for all 4 culture types, atypical cultures account for 69% of the total amount charged. CONCLUSION: Isolation of fungal or acid-fast organisms at the time of revision shoulder arthroplasty is rare and imposes a considerable financial burden when these atypical cultures are sent on a routine basis. The collection of fungal and acid-fast cultures should be reserved for patients in whom risk factors for these atypical organisms have been identified.

Undergoing an Arthroscopic Procedure Prior to Shoulder Arthroplasty is Associated With Greater Risk of Prosthetic Joint Infection.

PURPOSE: To utilize a national all-payer claims dataset to understand whether a history of a prior shoulder arthroscopy is associated with adverse outcomes or complications after the index shoulder arthroplasty itself. METHODS: The Symphony Integrated DataVerse, an all-payer claims database, was used to identify patients undergoing primary shoulder arthroplasty (hemiarthroplasty, anatomic total shoulder arthroplasty, or reverse total shoulder arthroplasty) between 2017 to 2018. Current Procedural Terminology codes were used to identify patients who had undergone a shoulder arthroscopic procedure on the ipsilateral side within 2 years before the arthroplasty. Multivariate logistic regression analyses were used to assess whether prior shoulder arthroscopy was associated with higher risks of wound complications, postoperative stiffness, mechanical complications, prosthetic joint infection, revision surgery and readmissions within 90 days of the arthroplasty. RESULTS: In total, 19,429 patients were included, of which 837 (4.3%) had undergone shoulder arthroscopy within 2 years before the arthroplasty. Prior shoulder arthroscopy was associated with a significantly higher risk of prosthetic joint infection (odds ratio [OR] 2.74 [95% confidence interval {CI} 1.51-4.69]; P < .001) within 90 days of the arthroplasty. The greatest risk of prosthetic joint infection was associated with arthroscopies that took place within 3 months before the arthroplasty (OR 5.32 [95% CI 1.42-15.14]; P = .005). CONCLUSIONS: Undergoing an arthroscopic procedure of the ipsilateral shoulder before undergoing an arthroplasty was associated with greater risk of prosthetic joint infection. Furthermore, it appears that patients who received arthroscopy within the 3 months before arthroplasty had the highest risk of prosthetic joint infections. Physicians should not only anticipate possible inferior outcomes in patients who have had prior arthroscopy, but also consider delaying the arthroplasty by at least 3 months after the arthroscopy to mitigate the risks of experiencing this costly adverse event. LEVEL OF EVIDENCE: III.