Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group.

BACKGROUND: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants. METHODS: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA. RESULTS: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001). CONCLUSION: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

BACKGROUND: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. METHODS: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. RESULTS: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006). CONCLUSION: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group.

BACKGROUND: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status. METHODS: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis. RESULTS: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort. CONCLUSION: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.

Radiographic Severity May Not be Associated with Pain and Function in Glenohumeral Arthritis.

BACKGROUND: Despite the routine use of plain radiographs to stratify the severity of glenohumeral osteoarthritis, little is known about the relationship between radiographic measures and patient-perceived pain and function. QUESTIONS/PURPOSES: (1) What radiographic findings are associated with worse pain and function in patients with glenohumeral osteoarthritis? (2) What demographic factors are associated with worse pain and function in patients with glenohumeral osteoarthritis? METHODS: This retrospective study included patients presenting for an initial office visit for primary glenohumeral osteoarthritis. Patients with other concurrent shoulder pathologic findings, prior surgery, lack of pain and functional scores, recent injection, or inadequate radiographs were excluded. Between January 2017 and January 2019, 3133 patients were eligible based on these inclusion criteria; 59% (1860) had outcome assessments and 48% (893) of those had radiographs. An additional 42% (378) of those with radiographs were excluded because of other shoulder findings, recent injection, prior surgery, or inadequate radiographs, leaving 16% (515 of 3133) who were fully analyzed in this study. A radiographic review included the joint space width, posterior humeral head subluxation, inferior humeral head osteophyte size, cystic change, and head asphericity. Additionally, radiographic arthritis was classified according to the Walch, Samilson-Prieto, and Kellgren-Lawrence classifications by two separate reviewers. Radiographic and demographic criteria as well as the presence of psychologic or mental illness were correlated with VAS Pain (range 1-10; minimal clinically important difference [MCID] 1.6), American Shoulder and Elbow Surgeons (ASES; range 0-100; MCID 13.6), Single Assessment Numeric Evaluation (SANE; range 0-100; MCID 14), and Simple Shoulder Test (SST; range 0-12; MCID 1.5) scores using univariate and multivariable regression analyses. RESULTS: After accounting for age, gender, and psychologic illness in the multivariable analysis, we found that patients with Samilson-Prieto Grade 4 arthrosis had lower VAS Pain scores (ß = -1.9; p = 0.02) than those with Grade 0 or 1 did; however, no clinically important associations were found between Samilson-Prieto Grade 4 and ASES (ß = 7; p = 0.25), SANE (ß = 4; p = 0.63), or SST (ß = 0.5; p = 0.62) scores. No clinically important associations were found between Kellgren-Lawrence Grade 3 and VAS Pain (ß = 1.4; p = 0.10), ASES (ß = -8; p = 0.22), SANE (ß = -13; p = 0.11), or SST scores (ß = 0.4; p = 0.66). Radiographic joint space and posterior subluxation also did not have any clinically important associations with VAS Pain or functional scores. In assessing Walch glenoid type, there was no clinically important association between glenoid type and VAS Pain (F = 3.1; p < 0.01), ASES (F = 1.9; p = 0.15), SANE (F = 0.45; p = 0.66), or SST scores (F = 0.76; p = 0.71). Men had higher SST scores than women did (ß = 2.0; p < 0.01), but there were no clinically important differences in VAS Pain (ß = -0.4; p = 0.04), ASES (ß = 6; p < 0.01), or SANE (ß = 4; p = 0.07) scores. No clinically important association was found between age or the presence of any psychologic illness and VAS Pain or functional scores. CONCLUSION: In patients with glenohumeral arthritis, no consistent clinically important differences in pain or function were discovered with respect to radiographic or demographic factors. Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity. Future studies can build on these findings by examining other non-radiographic or demographic factors that affect pain in patients with shoulder arthritis, such as psychological factors. LEVEL OF EVIDENCE: Level III, prognostic study.

Total shoulder arthroplasty using an inlay glenoid component for glenoid deficiency: mid- to long-term follow-up of a previously published cohort.

BACKGROUND: The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients. METHODS: We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores. RESULTS: Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P < .001]; external rotation, 18.8° [P < .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P < .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively. CONCLUSION: Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Preoperative Severe Acute Respiratory Syndrome Coronavirus 2 Polymerase Chain Reaction Test at Between 48 and 72 Hours Preoperatively is Safe for Patients Undergoing Primary and Revision Hip and Knee Arthroplasty: A Multicentre International Study.

BACKGROUND: Patients undergoing lower limb arthroplasty who are severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive at the time of surgery have a high risk of mortality. The National Institute for Health and Clinical Care Excellence and the British Orthopaedic Association advise self-isolation for 14 days preoperatively in patients at a high risk of adverse outcomes due to COVID-19. The aim of the study is to assess whether preoperative polymerase chain reaction (PCR) for SARS-CoV-2 could be performed at between 48 and 72 hours preoperatively with specific advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission. METHODS: A multicentre, international, observational cohort study of 1,000 lower limb arthroplasty cases was performed. The dual primary outcomes were 30-day conversion to SARS-CoV-2 positive and 30-day SARS-CoV-2 mortality. Secondary outcomes included 30-day SARS-CoV-2 morbidity. RESULTS: Of the 1,000 cases, 935 (94%) had a PCR between 48 and 72 hours preoperatively. All cases were admitted to and had surgery through a COVID-free pathway. Primary knee arthroplasty was performed in 41% of cases, primary hip arthroplasty in 40%, revision knee arthroplasty in 11%, and revision hip arthroplasty in 9%. Six percent of operations were emergency operations. No cases of SARS-CoV-2 were identified within the first 30 days. CONCLUSION: Preoperative SARS-CoV-2 PCR test between 48 and 72 hours preoperatively with advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission in conjunction with a COVID-free pathway is safe for patients undergoing primary and revision hip and knee arthroplasty. Preoperative SARS-CoV-2 PCR test alone may be safe but further adequately powered studies are required. This information is important for shared decision making with patients during the current pandemic.

What was the Prevalence of COVID-19 in Asymptomatic Patients Undergoing Orthopaedic Surgery in One Large United States City Mid-pandemic?

BACKGROUND: Many patients with coronavirus disease 2019 (COVID-19) are asymptomatic. The prevalence of COVID-19 in orthopaedic populations will vary depending on the time and place where the sampling is performed. The idea that asymptomatic carriers play a role is generalizable but has not been studied in large populations of patients undergoing elective orthopaedic surgery. We therefore evaluated this topic in one large, metropolitan city in a state that had the ninth-most infections in the United States at the time this study was completed (June 2020). This work was based on a screening and testing protocol that required all patients to be tested for COVID-19 preoperatively. QUESTIONS/PURPOSES: (1) What is the prevalence of asymptomatic COVID-19 infection in patients planning to undergo orthopaedic surgery in one major city, in order to provide other surgeons with a framework for assessing COVID-19 rates in their healthcare system? (2) How did patients with positive test results for COVID-19 differ in terms of age, sex, and orthopaedic conditions? (3) What proportion of patients had complications treated, and how many patients had a symptomatic COVID-19 infection within 30 days of surgery (recognizing that some may have been missed and so our estimates of event rates will necessarily underestimate the frequency of this event)? METHODS: All adult patients scheduled for surgery at four facilities (two tertiary care hospitals, one orthopaedic specialty hospital, and one ambulatory surgery center) at a single institution in the Philadelphia metropolitan area from April 27, 2020 to June 12, 2020 were included in this study. A total of 1295 patients were screened for symptoms, exposure, temperature, and oxygen saturation via a standardized protocol before surgical scheduling; 1.5% (19 of 1295) were excluded because they had COVID-19 symptoms, exposure, or recent travel based on the initial screening questionnaire, leaving 98.5% (1276 of 1295) who underwent testing for COVID-19 preoperatively. All 1276 patients who passed the initial screening test underwent nasopharyngeal swabbing for COVID-19 via reverse transcription polymerase chain reaction before surgery. The mean age at the time of testing was 56 ± 16 years, and 53% (672 of 1276) were men. Eighty-seven percent (1106), 8% (103), and 5% (67) were tested via the Roche, Abbott, and Cepheid assays, respectively. All patients undergoing elective surgery were tested via the Roche assay, while those undergoing nonelective surgery received either the Abbott or Cepheid assay, based on availability. Patients with positive test results undergoing elective surgery had their procedures rescheduled, while patients scheduled for nonelective surgery underwent surgery regardless of their test results. Additionally, we reviewed the records of all patients at 30 days postoperatively for emergency room visits, readmissions, and COVID-19-related complications via electronic medical records and surgeon-reported complications. However, we had no method for definitively determining how many patients had complications, emergency department visits, or readmissions outside our system, so our event rate estimates for these endpoints are necessarily best-case estimates. RESULTS: A total of 0.5% (7 of 1276) of the patients tested positive for COVID-19: five via the Roche assay and two via the Abbott assay. Patients with positive test results were younger than those with negative results (39 ± 12 years versus 56 ± 16 years; p = 0.01). With the numbers available, we found no difference in the proportion of patients with positive test results for COVID-19 based on subspecialty area (examining the lowest and highest point estimates, respectively, we observed: trauma surgery [3%; 2 of 68 patients] versus hip and knee [0.3%; 1 of 401 patients], OR 12 [95% CI 1-135]; p = 0.06). No patients with negative preoperative test results for COVID-19 developed a symptomatic COVID-19 infection within 30 days postoperatively. Within 30 days of surgery, 0.9% (11 of 1276) of the patients presented to the emergency room, and 1.3% (16 of 1276) were readmitted for non-COVID-19-related complications. None of the patients with positive test results for COVID-19 preoperatively experienced complications. However, because some were likely treated outside our healthcare system, the actual percentages may be higher. CONCLUSION: Because younger patients are more likely to be asymptomatic carriers of disease, surgeons should emphasize the importance of taking proper precautions to prevent virus exposure preoperatively. Because the rates of COVID-19 infection differ based on city and time, surgeons should monitor the local prevalence of disease to properly advise patients on the risk of COVID-19 exposure. Further investigation is required to assess the prevalence in the orthopaedic population in cities with larger COVID-19 burdens. LEVEL OF EVIDENCE: Level III, therapeutic study.

Incidence of peripheral nerve injury in revision total shoulder arthroplasty: an intraoperative nerve monitoring study.

BACKGROUND: The incidence of nerve injuries in revision total shoulder arthroplasty (TSA) is not well defined in the literature and may be higher than that in primary procedures, with 1 study reporting a complication rate of 50% for shoulder revisions. Given that continuous intraoperative nerve monitoring (IONM) can be an effective tool in diagnosing evolving neurologic dysfunction and preventing postoperative injuries, the purpose of this study was to report on IONM data and nerve injury rates in a series of revision TSAs. METHODS: A retrospective cohort review of consecutive patients who underwent revision TSA was performed from January 2016 to March 2020. Indications for revision included infection (n = 7); failed total arthroplasty and hemiarthroplasty secondary to pain, dysfunction, and/or loose components (n = 36); and periprosthetic fracture (n = 1). Of the shoulders, 32 underwent revision to a reverse TSA, 6 underwent revision to an anatomic TSA, and 6 underwent spacer placement. IONM data included transcranial electrical motor evoked potentials (MEPs), somatosensory evoked potentials, and free-run electromyography. The motor alert threshold was set at ≥80% signal attenuation in any peripheral nerve. Patients were screened for neurologic deficits immediately following surgery, prior to administration of an interscalene nerve block, and during the first 2 postoperative visits. Additional data collection included surgical indication, sex, laterality, age at surgery, procedure performed, body mass index, history of tobacco use, Charlson Comorbidity Index, medical history, and preoperative range of motion. RESULTS: A total of 44 shoulders in 38 patients were included, with a mean age of 63.2 years (standard deviation, 13.0 years). Of the procedures, 22.4% (n = 10) had an MEP alert, with 8 isolated to a single nerve (7 axillary and 1 radial) and 1 isolated to the axillary and musculocutaneous nerves. Only 1 patient experienced a major brachial plexus alert involving axillary, musculocutaneous, radial, ulnar, and median nerve MEP alerts, as well as ulnar and median nerve somatosensory evoked potential alerts. Age, sex, body mass index, Charlson Comorbidity Index, and preoperative range of motion were not found to be significantly different between cases in which an MEP alert occurred and cases with no MEP alerts. In the postoperative period, no minor or major nerve injuries were found whereas distal peripheral neuropathy developed in 4 patients (9.1%). CONCLUSION: Among 44 surgical procedures, no patients (0%) had a major or minor nerve injury postoperatively and 4 patients (9.1%) complained of distal peripheral neuropathy postoperatively. In this study, we have shown that through the use of IONM, the rate of minor and major nerve injuries can be minimized in revision shoulder arthroplasty.

Spacers for life: high mortality rate associated with definitive treatment of shoulder periprosthetic infection with permanent antibiotic spacer.

BACKGROUND: Periprosthetic joint infection following shoulder arthroplasty represents a challenging problem for orthopedic surgeons. Although recent studies have supported 2-stage exchanges, this treatment choice may not be appropriate for all patients. Definitive antibiotic spacer placement represents one treatment strategy with limited reported outcomes in the literature. The purpose of this study was to investigate the mortality rate and functional outcomes associated with definitive spacer placement. METHODS: A retrospective chart review identified 17 patients who were treated with definitive antibiotic spacer placement (18 spacers) and were followed up for a minimum of 2 years after surgery. The mortality rate over the study period was determined. Demographic information, clinical course, patient-reported outcomes (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, and Veterans RAND 12 [VR-12] score), infection parameters as defined by International Consensus Meeting criteria, radiographic evaluation findings, and rotator cuff integrity at the time of spacer placement were collected. RESULTS: Seventeen patients underwent treatment with retained antibiotic spacers at a mean age of 62.4 years (range, 50-73 years). Ten patients were women, and the mean body mass index was 30.5 (range, 22.9-39.9). Spacer placement occurred at a mean of 6.1 years (range, 0.48-14.9 years) following index arthroplasty. Five patients required spacer exchange. The most common organisms were Cutibacterium acnes (6) and methicillin-sensitive Staphylococcus aureus (6); in addition, methicillin-resistant S aureus (2), coagulase-negative Staphylococcus (2), Serratia marcescens (1), gram-positive cocci (1), Enterobacter faecalis (1), Enterobacter cloacae (1), diphtheroids (1), and an infection with negative culture findings (1) were observed. The mortality rate was 52.9% (9 of 17 patients). Among the 8 surviving patients, the mean American Shoulder and Elbow Surgeons score was 33.9 (range, 13.3-80.0), the mean Single Assessment Numeric Evaluation score was 35.6 (range, 0.0-80.0), the mean VR-12 mental score was 57.2 (range, 36.6-66.9), and the mean VR-12 physical score was 37.1 (range, 21.7-64.0) at a mean of 4.7 years (range, 2.0-8.8 years). CONCLUSION: Definitive antibiotic spacer placement is an acceptable method to treat infection in medically frail patients who have a high mortality risk. Spacer exchange may be necessary because of persistent infection, and functional results are poor.

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

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

Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study.

BACKGROUND: Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR). METHODS: Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery. RESULTS: A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05). CONCLUSION: Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.

Early repair of traumatic rotator cuff tears improves functional outcomes.

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

Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component.

HYPOTHESIS: The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component. METHODS: Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation. RESULTS: Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment. CONCLUSION: Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.

Predictors of acromial and scapular stress fracture after reverse shoulder arthroplasty: a study by the ASES Complications of RSA Multicenter Research Group.

BACKGROUND: Acromial (ASF) and scapular spine (SSF) stress fractures are well-recognized complications of reverse shoulder arthroplasty (RSA), but much of the current data are derived from single-center or single-implant studies with limited generalizability. This study from the American Shoulder and Elbow Surgeons (ASES) Complications of Reverse Shoulder Arthroplasty Multicenter Research Group determined the incidence of ASF/SSF after RSA and identified preoperative patient characteristics associated with their occurrence. METHOD: Fifteen institutions including 21 ASES members across the United States participated in this study. Patients undergoing either primary or revision RSA between January 2013 and June 2019 with a minimum 3-month follow-up were included. All definitions and inclusion criteria were determined using the Delphi method, an iterative survey process involving all primary investigators. Consensus was achieved when at least 75% of investigators agreed on each aspect of the study protocol. Only symptomatic ASF/SSF diagnosed by radiograph or computed tomography were considered. Multivariable logistic regression was performed to identify factors associated with ASF/SSF development. RESULTS: We identified 6755 RSAs with an average follow-up of 19.8 months (range, 3-94). The total stress fracture incidence rate was 3.9% (n = 264), of which 3.0% (n = 200) were ASF and 0.9% (n = 64) were SSF. Fractures occurred at an average 8.2 months (0-64) following RSA with 21.2% (n = 56) following a trauma. Patient-related factors independently predictive of ASF were chronic dislocation (odds ratio [OR] 3.67, P = .04), massive rotator cuff tear without arthritis (OR 2.51, P < .01), rotator cuff arthropathy (OR 2.14, P < .01), self-reported osteoporosis (OR 2.21, P < .01), inflammatory arthritis (OR 2.18, P < .01), female sex (OR 1.51, P = .02), and older age (OR 1.02 per 1-year increase, P = .02). Factors independently associated with the development of SSF included osteoporosis (OR 2.63, P < .01), female sex (OR 2.34, P = .01), rotator cuff arthropathy (OR 2.12, P = .03), and inflammatory arthritis (OR 2.05, P = .03). CONCLUSION: About 1 in 26 patients undergoing RSA will develop a symptomatic ASF or SSF, more frequently within the first year of surgery. Our results indicate that severe rotator cuff disease may play an important role in the occurrence of stress fractures following RSA. This information can be used to counsel patients about potential setbacks in recovery, especially among older women with suboptimal bone health. Strategies for prevention of ASF and SSF in these at-risk patients warrant further study. A follow-up study evaluating the impact of prosthetic factors on the incidence rates of ASF and SSF may prove highly valuable in the decision-making process.

Treatment of elbow periprosthetic joint infection: a systematic review of clinical outcomes.

BACKGROUND: Periprosthetic joint infection (PJI) of the elbow is a relatively common complication after total elbow arthroplasty (TEA), and its treatment is frequently variable. Few articles have provided direct comparisons of outcomes, making it difficult to draw conclusions from the available literature. This systematic review synthesizes the English-language literature on elbow PJI to quantify treatment outcomes. METHODS: The PubMed and Scopus databases were searched in December 2018. Our review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Keywords included "elbow replacement infection" and "elbow arthroplasty infection." A total of 1056 titles were identified; after application of the exclusion criteria, 41 studies met the screening criteria and underwent full-text review. Fifteen articles were included for the final analysis regarding demographic characteristics, risk factors, infecting organisms, success of eradication of infection based on surgical method, and functional outcomes of specific treatment regimens. RESULTS: Among the 15 articles selected, there were 309 TEA infections. Staphylococcus aureus was the most frequently isolated organism (42.4%), followed by coagulase-negative staphylococci (32.6%). Risk factors for the development of elbow PJI included rheumatoid arthritis, steroid use, an immunocompromised state, and previous elbow surgery. The rate of successful infection eradication was highest with 2-stage revision (81.2%) and lowest with irrigation and débridement for component retention (55.8%). The level of evidence was IV in 14 studies and III in 1 study. CONCLUSIONS: In this systematic review of TEA infections, Staphylococcus species represent the most common infecting organism. Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection.

Acromial stress fracture following reverse total shoulder arthroplasty: incidence and predictors.

BACKGROUND: Increased use of reverse total shoulder arthroplasty (RTSA) has led to an understanding of unique complications such as acromial stress fractures (ASFs). The factors associated with ASFs are not fully known. This study investigates the incidence and predictors of ASFs following RTSA. METHODS: All RTSAs performed at a single tertiary referral hospital were retrospectively reviewed. ASF findings were classified as a definitive acromial or scapular spine stress fracture based on radiographic findings or stress reaction based on clinical findings (pain and tenderness at the acromion or acromial spine) without radiographic changes. Preoperative and postoperative radiographs were reviewed for radiographic predictors of postoperative acromial stress pathology. Clinical factors and implant characteristics were also investigated. RESULTS: Between September 2010 and January 2017, a total of 1170 RTSAs were performed, with 958 cases (81.9%) having at least 3 months' clinical follow-up (mean, 407 days; range, 90-1698 days). There were 40 ASFs (4.2%) and 61 acromial stress reactions (6.4%). For fractures and reactions, symptom onset averaged 8.8 and 7.3 months (P = .37), respectively, with durations of 4.5 and 2.9 months (P = .02), respectively, following RTSA. Independent predictors of acromial stress pathology were female sex, decreased change in deltoid length, and increased preoperative glenohumeral center-of-rotation medialization. CONCLUSION: Acromion-related symptoms are common following RTSA. Female patients with increased preoperative center-of-rotation medialization had an increased incidence of ASFs. Although this study establishes which patients are at risk of ASFs, methods for prevention of ASFs in these patients remain unclear.

Computerised cognitive testing of individuals with Down's syndrome and Alzheimer's disease.

BACKGROUND: Although Alzheimer's disease neuropathology is present by age 40 years, in Down's syndrome, ante-mortem diagnosis is difficult. No standard for cognitive assessment is well established or easy to administer. METHOD: We used a simple, widely available computerised test (NeuroTrax Moderate to Severe Impairment Assessment Battery, Mindstreams, Newark, NJ) to evaluate 14 patients in this population. Orientation, memory, executive function, verbal function and visual spatial function were evaluated every 6 months for 18 months. RESULTS: Mean scaled scores in this longitudinal study were evaluated with repeated measures analysis of variance. Memory, executive function, verbal function and visual spatial function scores did not significantly change. There was no significant depression or anxiety on self-reported measures. CONCLUSIONS: Reproducibility of test results supports the reliability of this battery to quantify function and prospectively follow performance in this population over an 18-month period.

SBRT for Liver Tumors: What the Interventional Radiologist Needs to Know.

This review summarizes the clinical evidence supporting the utilization of stereotactic body radiotherapy (SBRT) for liver tumors, including hepatocellular carcinoma, liver metastases, and cholangiocarcinoma. Emerging prospective evidence has demonstrated the benefit and low rates of toxicity across a broad range of clinical contexts. We provide an introduction for the interventional radiologist, with a discussion of underlying themes such as tumor dose-response, mitigation of liver toxicity, and the technical considerations relevant to performing liver SBRT. Ultimately, we recommend that SBRT should be routinely included in the armamentarium of locoregional therapies for liver malignancies, alongside those liver-directed therapies offered by interventional radiology.

Midterm outcomes of suture anchor fixation for displaced olecranon fractures.

BACKGROUND: Displaced olecranon fractures constitute a challenging problem for elbow surgeons. The purpose of this study is to evaluate the role of suture anchor fixation for treating patients with displaced olecranon fractures. METHODS: A retrospective review was performed for all consecutive patients with displaced olecranon fractures treated with suture anchor fixation with at least 2 years of clinical follow-up. Surgical repair was performed acutely in all cases with nonmetallic suture anchors in a double-row configuration utilizing suture augmentation via the triceps tendon. Osseous union and perioperative complications were uniformly assessed. RESULTS: Suture anchor fixation was performed on 17 patients with displaced olecranon fractures. Functional outcome scores were collected from 12 patients (70.6%). The mean age at the time of surgery was 65.6 years, and the mean follow-up was 5.6 years. Sixteen of 17 patients (94%) achieved osseous union in an acceptable position. No hardware-related complications or fixation failure occurred. Mean postoperative shortened disabilities of the arm, shoulder, and hand (QuickDASH) score was 3.8±6.9, and mean Oxford Elbow Score was 47.5±1.0, with nine patients (75%) achieving a perfect score. CONCLUSIONS: Suture anchor fixation of displaced olecranon fractures resulted in excellent midterm functional outcomes. Additionally, this technique resulted in high rates of osseous union without any hardware-related complications or fixation failures. Level of evidence: IV.

Utilization of comorbidity indices to predict discharge destination and complications following total shoulder arthroplasty.

Background: Comorbidity indices can help identify patients at risk for postoperative complications. Purpose of this study was to compare different comorbidity indices to predict discharge destination and complications after shoulder arthroplasty. Methods: Retrospective review of institutional shoulder arthroplasty database of primary anatomic (TSA) and reverse (RSA) shoulder arthroplasties. Patient demographic information was collected in order to calculate Modified Frailty Index (mFI-5), Charlson Comorbidity Index (CCI), age adjusted CCI (age-CCI), and American Society of Anesthesiologists physical status classification system (ASA). Statistical analysis performed to analyze length of stay (LOS), discharge destination, and 90-day complications. Results: There were 1365 patients included with 672 TSA and 693 RSA patients. RSA patients were older and had higher CCI, age adjusted CCI, ASA, and mFI-5 (p < 0.001). RSA patients had longer lengths of stay (LOS), more likely to have an adverse discharge (p < 0.001), and higher reoperation rate (p = 0.003). Age-CCI was most predictive of adverse discharge (AUC 0.721, 95% CI 0.704-0.768). Discussion: Patients undergoing RSA had more medical comorbidities, experienced greater LOS, higher reoperation rate, and were more likely to have an adverse discharge. Age-CCI had the best ability to predict which patients were likely to require higher-level discharge planning.