Regional variation from 2013 to 2021 in primary total shoulder arthroplasty utilization, reimbursement, and patient populations.

BACKGROUND: Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. RESULTS: Between 2013 and 2021 TSA utilization increased by 121.8%, nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; P < .001). The average comorbidity burden of patients was decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (P < .001). CONCLUSION: This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

Routine immediate postoperative radiographs rarely identify unknown complications after shoulder arthroplasty.

BACKGROUND: Intraoperative complications after shoulder arthroplasty (SA) are uncommon, yet surgeons continue to obtain immediate postoperative radiographs despite prior literature questioning the efficacy of these images. There is a paucity of literature describing the role of immediate postoperative radiographs in revision SA. This study aimed to evaluate the utility of immediate postoperative radiographs in identifying intraoperative complications leading to a change in care after primary or revision SA. We hypothesized that routine postoperative ("survey") radiographs would not provide a high diagnostic yield in identifying early complications requiring a change in postoperative management. METHODS: A retrospective review of 4063 SAs (1298 primary anatomic total shoulder arthroplasties [aTSAs], 2162 primary reverse shoulder arthroplasties [RSAs], 129 revision aTSAs, and 474 revision RSAs) was performed from a multi-institutional arthroplasty database. All shoulders were evaluated with a single immediate postoperative (survey) radiograph that was read by a musculoskeletal radiologist and by the treating orthopedic surgery team. The radiology reports of all 4063 immediate postoperative radiographs were reviewed to determine whether complications had been identified. For patients in whom complications were identified, the medical record was then reviewed to determine whether the survey radiograph resulted in a return to the operating room or a change in management between the surgical procedure and the first postoperative clinic visit with radiographic evaluation. RESULTS: Complications were reported by a radiologist on the basis of immediate postoperative radiographs in 10 of 4063 shoulders (0.2%, or 1 of every 500 arthroplasties). Complications were reported after 4 primary RSAs, 4 revision aTSAs, and 2 revision RSAs; no complication was reported after any of the primary aTSAs. Of the 10 complications, only 3 were unknown to the treating surgeon following the operation and none altered immediate postoperative management. Early complications were reported at a rate of 1% after revision arthroplasty vs. 0.1% after primary arthroplasty (P = .001). Additionally, revision aTSA was found to have a higher rate of complications reported on radiographs, with a rate of 3.1%, compared with revision RSA, at 0.4% (P = .021). CONCLUSION: The radiology reports of routine immediate postoperative radiographs rarely identified postoperative complications (0.2%). In all cases, postoperative management remained unaltered until the time of the first postoperative visit. The value and medicolegal implications of immediate postoperative radiographs may inform the decision to abandon obtaining these studies routinely.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial.

BACKGROUND: Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. MATERIALS AND METHODS: A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. RESULTS: No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. CONCLUSION: When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Calcific Tendonitis of the Shoulder: Protector or Predictor of Cuff Pathology? A Magnetic Resonance Imaging-Based Study.

PURPOSE: The purpose of this investigation is to assess the incidence of rotator cuff tears in cases of calcific tendonitis and evaluate for differences in the incidences of rotator cuff tears by magnetic resonance imaging (MRI) between calcific lesions of different morphology, size, or location. METHODS: This single-center study involved a retrospective chart review searching for patients from January 2010 to April 2017 with a diagnosis of calcific tendonitis of the shoulder based on review of all MRI reads done on patients with shoulder pain. Anteroposterior radiographic and MRI studies were reviewed by a musculoskeletal radiologist to assess calcific tendonitis morphology, size, distance from cuff insertion, and any rotator cuff tear. An additional radiologist evaluated calcific tendonitis size, morphology, and location to evaluate the reliability of these variables. RESULTS: In the final cohort of 318 shoulders with calcific tendonitis, the incidence of concomitant rotator cuff tears was 56%. Of all 177 tears, 164 (93%) were partial-thickness and 13 (7%) were complete. Type III calcification morphology (cloudy with soft contour) was most frequently associated with rotator cuff tears and demonstrated an increased odds of tear by a factor of 1.8 (CI95% 1.1-2.9).There was no statistical difference regarding calcification size or location prognosticating rotator cuff tears or tear thickness. Intraclass correlation coefficients for calcification size, morphology, and location were 0.78, 0.30, and 0.50, respectively. CONCLUSIONS: The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. Cloudy-appearing calcified lesions showed a significant association with rotator cuff tears with an odds ratio of 1.8. Specific locations or sizes of calcified lesions do not appear to be reliable factors to predict concomitant rotator cuff tears. Interobserver agreement for these radiographic variables ranged from fair to substantial and prompt a cautious interpretation of these results. LEVEL OF EVIDENCE: IV Retrospective Case Series.

Use of Compressive Osseointegration Endoprostheses for Massive Bone Loss From Tumor and Failed Arthroplasty: A Viable Option in the Upper Extremity.

BACKGROUND: Endoprostheses using principles of compressive osseointegration have shown good survivorship in several studies involving the lower extremity; however, no series to our knowledge have documented the use of this technology in the management of massive bone loss in the upper limb. QUESTIONS/PURPOSES: (1) What proportion of upper extremity implants using compressive osseointegration fixation principles achieved durable short-term fixation, and what were the modes of failure? (2) What surgical complications resulted from reconstruction using this technique? METHODS: A multiinstitutional retrospective review identified nine patients (five women; four men) who underwent 13 endoprosthetic replacements between 2003 and 2014 using compressive osseointegration (Compliant® Pre-stress Device [CPS]; Biomet Inc, Warsaw, IN, USA) in the upper extremity, including two proximal humeri, two humeral diaphyses, seven distal humeri, and two proximal ulna. During the early part of that period, the indication for use of a compressive prosthesis in our centers was revision of a previous tumor reconstruction (allograft-prosthetic composite or stemmed endoprosthetic reconstruction) (three patients; five implants), or revision arthroplasty with massive bone loss (three patients, four implants); more recently, indications became somewhat more permissive and included posttraumatic bone loss (one patient, one implant), primary bone sarcoma, and resections with very short remaining end segments after diaphyseal resections (two patients, three implants). Minimum followup was 24 months; one patient (one implant) was lost to followup before that time with the implant intact at 14 months and no patients have died. The mean age of the patients was 45 years (range, 21-62 years). Mean followup was 68 months (range, 24-141 months). Implant revision for any cause and for failure of the CPS mechanism was recorded. Modes of failure were categorized as soft tissue, aseptic loosening, structural, infection, and tumor progression; CPS modes of failure were defined as lack of fixation, with or without bone or implant fracture. RESULTS: Of the 12 implants accounted for beyond 2 years, six had undergone revision of any kind. Only two revisions in two patients were attributable to lack of CPS fixation at the bone-implant interface; one of the patients also had periprosthetic and implant fracture develop through the traction bar. Other modes of failure were aseptic loosening of the standard ulnar component (two patients, two implants), bushing wear (one patient; one implant) and infection resulting in two-stage exchange and free soft tissue transfer with retention of the CPS spindle (one patient, one implant). Complications for all nine patients included one transient radial nerve palsy, one ulnar nerve sensory neurapraxia, one superficial infection, and two glenohumeral subluxations, one underwent revision surgery with implantation of a constrained liner. CONCLUSIONS: A compressive osseointegration endoprosthesis is an option for very difficult revisions or sarcoma resection in the upper extremity in which the remaining segment of host bone is too short for a conventional prosthesis. However, surgeons must inform patients that these are salvage operations, and revision surgery is common. Long-term followup of more patients is necessary to further document the survivorship of these implants in the upper extremity. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Polyethylene dissociation from humeral stem status after reverse total shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is an important treatment option for 4-part proximal humerus fractures in the elderly and arthrosis of the glenohumeral joint with incompetence of the rotator cuff. Unique complications do occur with use of this type of prosthesis. METHODS: We present 4 cases of polyethylene dissociation after RSA. RESULTS: In a series of 549 patients who underwent RSA, the incidence of polyethylene dissociation was found to be 0.7%. CONCLUSIONS: Polyethylene dissociation is a rare complication after RSA. Surgeons should be aware of this possibility if a closed reduction of an RSA dislocation is not possible.

Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty.

BACKGROUND: Efficacy of tranexamic acid (TXA) remains unproven in the setting of shoulder arthroplasty. The purpose of this study was to determine the effects of TXA on perioperative blood loss and drain output in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: We conducted a retrospective comparison of 77 TSAs and 94 RTSAs performed in 168 patients. TXA was administered intravenously in 35 TSA and 42 RTSA patients. Changes in hemoglobin (Hgb), hematocrit (Hct), drain output, and total blood loss were reviewed with univariate analysis and additional multivariate regression examining the cofactors of age, body mass index, American Society of Anesthesiologists status, and gender of each patient. RESULTS: Use of TXA in TSA led to a significant decrease in total blood loss (679 mL vs. 910 mL; P < .001), change in Hgb (1.8 mg/dL vs. 2.6 mg/dL; P < .001), and drop in Hct (5.2 vs. 7.0; P < .001). Similarly, RTSA also had significantly less total blood loss with the use of TXA (791 mL vs. 959 mL; P < .001), change in Hgb (2.3 mg/dL vs. 2.9 mg/dL; P < .001), and change in Hct (6.4 vs. 8.3; P < .001). TXA also significantly decreased drain output in both TSA (99 mL vs. 235 mL; P < .001) and RTSA (180 mL vs. 370 mL; P < .001). CONCLUSIONS: Use of TXA perioperatively among patients undergoing primary shoulder arthroplasty can decrease perioperative blood loss, change in Hgb and Hct, and postoperative drain output.

Cost utility analysis of reverse total shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty provides satisfactory outcomes, but its cost-effectiveness is unproven. We prospectively analyzed outcomes and costs for primary reverse shoulder arthroplasty. METHODS: Thirty serial patients (16 women and 14 men; mean age, 74.1 years [range, 61.1-87.3 years]) with rotator cuff arthropathy had active motion recorded and completed function tests (visual pain analog scale; Simple Shoulder Test; American Shoulder and Elbow Surgeons Shoulder Outcome score; EuroQol; and Short Form-36 Health Survey) preoperatively and postoperatively at 1 and 2 years. Costs included professional fees, operating room and supply costs, and hospital care. Changes were compared by the Wilcoxon signed rank test, and quality-adjusted life-years were calculated preoperatively and postoperatively. RESULTS: Twenty-seven patients completed the study. Clinical and functional outcomes demonstrated significant improvement (P < .05). Significantly improved (P < .05) Short Form-36 subgroups included physical functioning, role limitations due to physical health, bodily pain, vitality, and physical composite score. EuroQol dimensions of usual activities and pain/discomfort improved significantly (P < .05). Calculations with the SF-6D showed that median QALYs improved from 6.56 preoperatively to 7.43 at 1-year follow-up (P <.09) and from 6.56 preoperatively to 7.58 at 2-year follow-up (P <.003). The increase in QALYs calculated from the EQ-5D was somewhat greater, changing from 6.21 preoperatively to 7.69 at 1-year follow-up (P <.0001) and from 6.13 to 8.10 at 2-year follow-up (P <.04). Mean cost was $21,536. Cost utility at 2 years was $26,920/quality-adjusted life-year by the Short Form 6 Dimensions and $16,747/quality-adjusted life-year by the EuroQol. CONCLUSION: EuroQol and Short Form-36 results demonstrated modestly cost-effective (<$50,000/quality-adjusted life-year) improvement for cuff tear arthropathy patients after primary reverse shoulder arthroplasty. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Preoperative patient education reduces in-hospital falls after total knee arthroplasty.

BACKGROUND: Inpatient hospital falls after orthopaedic surgery represent a major problem, with rates of about one to three falls per 1000 patient days. These falls result in substantial morbidity for the patient and liability for the institution. QUESTIONS/PURPOSES: We determined whether preoperative patient education reduced the rate of in-hospital falls after primary TKA and documented the circumstances and the injuries resulting from the falls. PATIENTS AND METHODS: We reviewed data from all 244 patients who underwent primary TKA at a single institution between March and November 2009. Seventy-two patients of one surgeon were enrolled in a preoperative nurse-led education program. This group was compared with a control group of 172 patients who concurrently underwent TKA at the same institution but did not receive preoperative education. RESULTS: More control patients had in-hospital falls than those in the education group: seven (one of whom had two falls) of 172 (4%) versus none of 72 (0%), respectively. Three of the eight falls resulted in a serious injury, including one wound dehiscence and one wound hematoma that both required repeat surgery and one clavicle fracture. CONCLUSIONS: Inpatient falls after TKA may be associated with major complications. Our preoperative patient education reduced these falls and is now mandatory for patients undergoing TKA at our institution.

Reverse shoulder replacement for patients with inflammatory arthritis.

PURPOSE: Patients with inflammatory arthritis frequently develop destructive shoulder arthritis and rotator cuff tearing. Reconstruction with anatomical shoulder replacement produces lesser results than for other etiologies such as osteoarthritis. We postulated that reconstruction with reverse shoulder prostheses would lead to early satisfactory results for these patients. METHODS: We carried out a retrospective review of 19 shoulders treated with reverse shoulder prostheses at a mean follow-up of 37 months. We rated patients' pain using a visual analog pain scale (VAPS) and noted active range of motion in forward elevation, abduction, and external rotation. American Shoulder and Elbow Society and Simple Shoulder Test SST scores were available for 12 patients preoperatively and 16 postoperatively. We graded final results using the modified Neer scale. RESULTS: Preoperatively, the mean VAPS was 6.5, with average flexion of 68, abduction 66, and external rotation 23°. The American Shoulder and Elbow Society score averaged 27 and the SST 1. Postoperatively, the VAPS was 1 and flexion was 138°, abduction 134°, and external rotation 52°. The mean ASES score increased to 76 and the SST to 8. There were 12 excellent, 5 satisfactory, and 2 unsatisfactory results. Complications included 2 scapular spine fractures, 1 acromial fracture, 1 dislocation, and 1 ulnar neuropathy. We found scapular notching in 42% of the shoulders. Six shoulders had grade 1 notching, and 2 shoulders grade 2 notching. There was no evidence of glenoid loosening, but we saw complete bone-cement radiolucency around 2 cemented stems. CONCLUSIONS: At early follow-up, reverse shoulder arthroplasty for the shoulder damaged by inflammatory arthritis and with a deficient rotator cuff can provide noteworthy improvement for most patients.

Analysis of total joint arthroplasty costs in Chinese patients.

All charges for patients undergoing unilateral and bilateral hip or knee arthroplasties at 1 hospital in Beijing, China, were identified and assigned to 1 of 11 charge categories: hospital room, nursing, radiology, laboratory, anesthesia, surgery, prosthesis, pharmacy, blood transfusion, materials, and miscellaneous. The prosthesis and pharmacy charges at this institution accounted for approximately 80% of the total charges; compared with published data from institutions in North America and Taiwan, these 2 charges accounted for a greater percentage of total charges. In distinction, labor costs in China accounted for a lower percentage of total charges. Importantly, because the percentage of costs covered by medical insurance was relatively low, a substantial financial burden was imposed on patients that may limit access to joint arthroplasty in China.

More hypotension in patients taking antihypertensives preoperatively during shoulder surgery in the beach chair position.

PURPOSE: Hypotension is common in patients undergoing surgery in the sitting position under general anesthesia, and the risk may be exacerbated by the use of antihypertensive drugs taken preoperatively. The purpose of this study was to compare hypotensive episodes in patients taking antihypertensive medications with normotensive patients during shoulder surgery in the beach chair position. METHODS: Medical records of all patients undergoing shoulder arthroscopy during a 44-month period were reviewed retrospectively. The primary endpoint was the number of moderate hypotensive episodes (systolic blood pressure ≤ 85 mmHg) during the intraoperative period. Secondary endpoints included the frequency of vasopressor administration, total dose of vasopressors, and fluid administered. Values are expressed as mean (standard deviation). RESULTS: Of 384 patients who underwent shoulder surgery, 185 patients were taking no antihypertensive medication, and 199 were on at least one antihypertensive drug. The antihypertensive medication group had more intraoperative hypotensive episodes [1.7 (2.2) vs 1.2 (1.8); P = 0.01] and vasopressor administrations. Total dose of vasopressors and volume of fluids administered were similar between groups. The timing of the administration of angiotensin-converting enzyme inhibitors and of angiotensin receptor antagonists (≤ 10 hr vs > 10 hr before surgery) had no impact on intraoperative hypotension. CONCLUSIONS: Preoperative use of antihypertensive medication was associated with an increased incidence of intraoperative hypotension. Compared with normotensive patients, patients taking antihypertensive drugs preoperatively are expected to require vasopressors more often to maintain normal blood pressure.

Shoulder arthroplasty in the paraplegic patient.

INTRODUCTION: Shoulder arthroplasty in the paraplegic patient is a challenging procedure, because of the patients' unique demands on the shoulder. Previous information on the outcomes of this surgery in the literature is quite limited. Our experience in the prosthetic reconstruction of the arthritic shoulder in patients with pre-existing paraplegia was reviewed to define the results and identify any complications or the need for revision surgery. METHOD: Six patients were identified as eligible for inclusion. One patient had a humeral head replacement (HHR) and the remaining patients total shoulder arthroplasty (TSA). The average age at time of surgery was 68.7 years. The most common cause of the paraplegia was poliomyelitis, which was present in 3 patients. The other etiologies were transverse myelitis, spina bifida, and familial spastic paraparesis. Patients were followed for an average of 84 months, ranging from a minimum of 24 months up to 200 months. Results were graded according to a modified Neer classification. RESULTS: The results were excellent in 1 shoulder, satisfactory in 4, and unsatisfactory in only 1. One patient continued to have severe pain post-operatively, but good pain relief was achieved in the remaining shoulders. Average postoperative elevation was 122 degrees, ranging from 90 degrees to 150 degrees. Complications included pressure ulceration, pneumonia, brachial plexopathy, and humeral fracture. CONCLUSIONS: Satisfactory outcomes in pain relief and range of motion can be accomplished with shoulder arthroplasty in the paraplegic patient. Complications are frequent and careful management of the patient necessary to minimize their occurrence.

Revision total shoulder arthroplasty for painful humeral head replacement with glenoid arthrosis.

HYPOTHESIS: After humeral head replacement, revision total shoulder arthroplasty may become necessary for painful glenoid arthrosis. The hypothesis of this study was revision surgery would significantly relieve the patients' pain. MATERIALS AND METHODS: This report retrospectively reviewed the results of revision total shoulder arthroplasty in seventeen patients with a painful humeral head replacement and glenoid arthrosis. The mean time interval to revision was 36.4 months (6-144) and the patients were followed for an average of 56.1 months (24-119). Outcomes were graded with the Neer classification. RESULTS: There were 7 (41.2%) excellent, 5 (29.4%) satisfactory, and 5 (29.4%) unsatisfactory results. The visual analogue pain score decreased from 8.8 to 2.4, flexion improved from 73 degrees to 124, abduction from 63 to 115.6, and external rotation from 12.1 to 46.8. In 13 shoulders with sufficient data, the ASES score was 76.8 and the SST 9.5. It was necessary to revise the humeral stem in 12 of the 17 procedures, typically for poor stem position or improved exposure. CONCLUSION: Conversion of humeral head replacement to total shoulder arthroplasty can be accomplished with excellent results, but the surgery is complex and unsatisfactory results are frequent. LEVEL OF EVIDENCE: Level 4; Retrospective case series, no control group.

Clinical Efficacy of Liposomal Bupivacaine: A Systematic Review of Prospective, Randomized Controlled Trials in Orthopaedic Surgery.

BACKGROUND: There has been a surge in interest with regard to the utility of liposomal bupivacaine as part of a perioperative pain management protocol. The current study was proposed to critically assess the efficacy of liposomal bupivacaine as a local anesthetic for pain relief following orthopaedic procedures. METHODS: A systematic review of prospective, randomized trials involving liposomal bupivacaine was performed using searches of the PubMed, Embase, and Cochrane databases. The primary outcomes of interest included postoperative subjective pain scores and narcotic consumption. The length of stay and postoperative mobility were reviewed as secondary outcomes. RESULTS: Twenty-seven studies met inclusion criteria and were included for review. Twelve of 17 studies concluded that periarticular or local infiltrative liposomal bupivacaine offered no additive benefit compared with other local anesthetic injections. Peripheral nerve blocks without liposomal bupivacaine conferred more optimal pain relief and decreased narcotic consumption in the immediate postoperative period when compared with liposomal bupivacaine, with no differences thereafter. Twelve studies listed a conflict of interest related to the drug manufacturer (Pacira Pharmaceuticals). Eight of these studies (67%) demonstrated clinical superiority of liposomal bupivacaine when compared with the study control. In the 15 studies that did not show a conflict of interest, only 1 study (7%) demonstrated therapeutic superiority with use of periarticular liposomal bupivacaine when compared with a historical cohort that received no local or regional anesthesia. CONCLUSIONS: Current prospective, randomized controlled trials in patients undergoing orthopaedic surgery fail to support the routine use of liposomal bupivacaine compared with other local injectable analgesics, particularly in the setting of knee replacement surgery. We were unable to find consistent support for the potential of superior pain relief and narcotic use reduction with the use of liposomal bupivacaine. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ninety-day readmissions following reverse total shoulder arthroplasty.

BACKGROUND: An adequate characterization of 90-day readmissions after primary reverse total shoulder arthroplasty (RTSA) on a national level remains to be undertaken. As bundled payment models become more prevalent, an improved understanding of readmission data will help to predict resource utilization and expenses. METHODS: All adult patients who underwent elective primary RTSA in 2014 in the National Readmission Database were included in the analysis. Two cohorts were created based on 90-day readmission status. Multivariate analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified. Total hospital resource utilization was calculated. RESULTS: An estimated 25,196 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. Diabetes (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.14-1.78), hypertension (OR, 1.63; 95% CI, 1.28-2.08), paralysis (OR, 3.61; 95% CI, 1.63-7.97), and solid tumor without metastasis (OR, 2.72; 95% CI, 1.21-6.12) were identified as independent predictors of 90-day readmission. Ninety-day readmissions were associated with a significant increase in cost (P = .02). The most common related reason for 90-day readmission was hardware-related complications at all time points. CONCLUSION: Although uncommon, 90-day readmissions after primary RTSA are associated with significant patient morbidity and consequently substantial hospital costs.

Analysis of 90-Day Readmissions After Total Shoulder Arthroplasty.

BACKGROUND: The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed. PURPOSE: To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated. RESULTS: An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases (P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points. CONCLUSION: While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

Shoulder hemiarthroplasty for steroid-associated osteonecrosis.

Currently, there is little information on the outcome of humeral head replacement for steroid-associated osteonecrosis of the humeral head. The purpose of this study was to evaluate the outcome of patients who underwent humeral head replacement for steroid-associated osteonecrosis to determine the results, risk factors for an unsatisfactory outcome, and rates of revision surgery. Between 1980 and 2000, 32 shoulder hemiarthroplasties were performed for steroid-associated osteonecrosis. We included 31 hemiarthroplasties in 25 patients with a minimum 2-year follow-up (mean, 12.0 years) in the study. The mean age of the 23 female and 9 male patients was 49.4 years at the time of surgery (range, 25-86 years). Overall, mean pain scores decreased from 4.6 to 2.6 (P < .0001). However, moderate or severe pain was reported in 12 shoulders (38%) at the most recent follow-up, 2 of them requiring implant revision. The mean preoperative to postoperative active elevation increased from 92 degrees to 139 degrees (P < .0001), and external rotation increased from 36 degrees to 65 degrees (P < .0001). According to a modified Neer result rating system, there were 13 excellent results (42%), 4 satisfactory results (13%), and 14 unsatisfactory results (45%). Improvement in pain and function most often occurred after hemiarthroplasty as a treatment for steroid-associated osteonecrosis of the humeral head. However, there are a large number of unsatisfactory results related to glenoid cartilage wear over time.