Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients.

BACKGROUND: The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS: A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS: The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION: In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.

Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis.

BACKGROUND: Proximal humerus fractures are the second-most common fragility fracture in older adults. Although reverse total shoulder arthroplasty (RTSA) is a promising treatment strategy for proximal humerus fractures with favorable clinical and quality of life outcomes, it is associated with much higher, and possibly prohibitive, upfront costs relative to nonoperative treatment and other surgical alternatives. QUESTIONS/PURPOSES: (1) What is the cost-effectiveness of open reduction internal fixation (ORIF), hemiarthroplasty, and RTSA compared with the nonoperative treatment of complex proximal humerus fractures in adults older than 65 years from the perspective of a single-payer Canadian healthcare system? (2) Which factors, if any, affect the cost-effectiveness of ORIF, hemiarthroplasty, and RTSA compared with nonoperative treatment of proximal humerus fractures including quality of life outcomes, cost, and complication rates after each treatment? METHODS: This cost-utility analysis compared RTSA, hemiarthroplasty, and ORIF with the nonoperative management of complex proximal humerus fractures in adults older than 65 years over a lifetime time horizon from the perspective of a single-payer healthcare system. Short-term and intermediate-term complications in the 2-year postoperative period were modeled using a decision tree, with long-term outcomes estimated through a Markov model. The model was initiated with a cohort of 75-year-old patients who had a diagnosis of a comminuted (three- or four-part) proximal humerus fractures; 90% of the patients were women. The mean age and gender composition of the model's cohort was based on a systematic review conducted as part of this analysis. Patients were managed nonoperatively or surgically with either ORIF, hemiarthroplasty, or RTSA. The three initial surgical treatment options of ORIF, hemiarthroplasty, and RTSA resulted in uncomplicated healing or the development of a complication that would result in a subsequent surgical intervention. The model reflects the complications that result in repeat surgery and that are assumed to have the greatest impact on clinical outcomes and costs. Transition probabilities and health utilities were derived from published sources, with costs (2020 CAD) sourced from regional costing databases. The primary outcome was the incremental cost-utility ratio, which was calculated using expected quality-adjusted life years (QALYs) gained and costs. Sensitivity analyses were conducted to explore the impact of changing key model parameters. RESULTS: Based on both pairwise and sequential analysis, RTSA was found to be the most cost-effective strategy for managing complex proximal humerus fractures in adults older than 65 years. Compared with nonoperative management, the pairwise incremental cost-utility ratios of hemiarthroplasty and RTSA were CAD 25,759/QALY and CAD 7476/QALY, respectively. ORIF was dominated by nonoperative management, meaning that it was both more costly and less effective. Sequential analysis, wherein interventions are compared from least to most expensive in a pairwise manner, demonstrated ORIF to be dominated by hemiarthroplasty, and hemiarthroplasty to be extendedly dominated by RTSA. Further, at a willingness-to-pay threshold of CAD 50,000/QALY, RTSA had 66% probability of being the most cost-effective treatment option. The results were sensitive to changes in the parameters for the probability of revision RTSA after RTSA, the treatment cost of RTSA, and the health utilities associated with the well state for all treatment options except ORIF, although none of these changes were found to be clinically realistic based on the existing evidence. CONCLUSION: Based on this economic analysis, RTSA is the preferred treatment strategy for complex proximal humerus fractures in adults older than 65 years, despite high upfront costs. Based on the evidence to date, it is unlikely that the parameters this model was sensitive to would change to the degree necessary to alter the model's outcome. A major strength of this model is that it reflects the most recent randomized controlled trials evaluating the management of this condition. Therefore, clinicians should feel confident recommending RTSA for the management of proximal humerus fractures in adults older than 65 years, and they are encouraged to advocate for this intervention as being a cost-effective practice, especially in publicly funded healthcare systems wherein resource stewardship is a core principle. Future high-quality trials should continue to collect both clinical and quality of life outcomes using validated tools such as the EuroQOL-5D to reduce parameter uncertainty and support decision makers in understanding relevant interventions' value for money. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient.

BACKGROUND: Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly. METHODS: We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up. RESULTS: Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%. CONCLUSION: In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

Interscalene brachial plexus catheter versus single-shot interscalene block with periarticular local infiltration analgesia for shoulder arthroplasty.

BACKGROUND: Interscalene brachial plexus block is a commonly employed regional anesthetic technique for total shoulder arthroplasty, and a continuous catheter is often placed to extend the analgesic benefit of the block. As periarticular local infiltration analgesia (LIA) for total joint arthroplasty is a re-emerging trend, we evaluated the analgesic efficacy of continuous interscalene block (CISB) compared to single-shot interscalene block (SSISB) with LIA. METHODS: We conducted a retrospective review of 130 consecutive patients treated by one surgeon in a single institution, with 12 patients excluded for history of chronic opioid tolerance and two for incomplete data. The SSISB with LIA treatment group (N.=53) was compared to a control group who received CISB (N.=63). Primary end points were a difference in pain score (0-10 numeric rating scale) and opioid requirements as oral morphine equivalents (OMEs) on postoperative days (PODs) 0 and 1. Secondary end points included nausea and vomiting, length of hospital stay, block failure rate, adverse events due to block, and 30-day readmission. RESULTS: When compared to SSISB with LIA, patients who received CISB exhibited decreased opioid requirements in OMEs on POD 0 (11.9 mg vs. 28.7 mg, P<0.01) and POD 1 (24.0 mg vs. 50.3 mg, P<0.01). There was no significant difference in pain on POD 0, but a statistically significant decrease in average pain scores with CISB on POD 1 (2.3 vs. 4.3, P<0.01). CONCLUSIONS: SSISB with LIA may provide clinically similar postoperative analgesia compared to CISB, but with escalating doses of opioid requirements.

Eficacia y seguridad del tapentadol frente a tramado' en analgesia postoperatoria de la artroscopia de hombro / Efficacy and safety of tapentadol versus tramado' in postoperative analgesia of shoulder arthroscopy

Introducción: El dolor postoperatorio asociado a la artroscopia de hombro es de moderada a severa intensidad. Esto obliga al uso de opiáceos o bloqueos nerviosos para su control. Los efectos secundarios asociados al uso de opioides, principalmente en forma de náuseas, vómitos y estreñimiento, condiciona su uso. Material y métodos: El objetivo principal del estudio fue determinar la eficacia y seguridad del manejo del dolor agudo postoperatorio de la artroscopia de hombro con tapentadol de liberación retardada frente a tramadol de liberación retardada. Resultados: En este estudio se ha demostrado que el tapentadol de liberación retardada es más eficaz y tiene menor incidencia de efectos secundarios que el tramadol en el control del dolor agudo postoperatorio en la artroscopia de hombro. Esto permite acortar los tiempos de estancia hospitalaria y de rehabilitación. Conclusiones: El tapentadol, debido a su doble mecanismo de acción, de inhibición de la recaptación de norepinefrina, además de agonista opioide mu, es un analgésico con mejor perfil de tolerabilidad y menos efectos secundarios, comparado con el tramadol. Podemos concluir que el tapentadol es una alternativa eficaz y segura en el control del dolor agudo postoperatorio de moderada a severa intensidad (AU)

Introduction: Postoperative pain associated with shoulder arthroscopy is of moderate-severe intensity. This forces the use of opiates or nerve blocks for their control. Side effects associated with the use of opioids, mainly in the form of nausea, vomiting and constipation condition their use. Material and methods: The main objective of the study was to determine the efficacy and safety of postoperative pain management of shoulder arthroscopy with delayed-release tapentadol versus delayed-release tramadol. Results: This study has shown that delayed-release tapentadol is more effective and has fewer side effects than tramadol in the management of postoperative shoulder arthroscopy pain. This allows shortening the hospital stay and rehabilitation time. Conclusions: Tapentadol due to its norepinephrine reuptake inhibitory properties, in addition to the mu agonist, is a better analgesic than tramadol and has fewer side effects.We can conclude that tapentadol is an effective and safe alternative in the management of severe moderate postoperative pain (AU)

Combined Selective Nerve Blockade and Local Infiltration Analgesia in a Total Shoulder Arthroplasty Patient With Chronic Pain and Severe Restrictive Lung Disease: A Case Report.

Interscalene brachial plexus block is considered the most complete postoperative analgesia after total shoulder arthroplasty. Interscalene brachial plexus block-induced ipsilateral hemidiaphragmatic paralysis may not be tolerated in patients with preexisting pulmonary disease. Selective distal nerve blocks avoid the risk of phrenic nerve block; however, they may provide incomplete analgesia to the glenohumeral joint. We report a case of combined selective suprascapular and axillary nerve blockade in combination with local infiltration analgesia in a patient with severe lung disease undergoing total shoulder arthroplasty. This case highlights the local infiltration analgesia technique of the shoulder joint and current diaphragm-sparing regional anesthesia blocks.

Composite reverse shoulder arthroplasty can provide good function and quality of life in cases of malignant tumour of the proximal humerus.

PURPOSE: Management of proximal humeral tumours remains a surgical challenge. No study to date has assessed the quality of life scores following the composite reverse shoulder arthroplasty for this indication. We, therefore, evaluated function and quality of life following reconstruction with allograft for malignant tumour of the humerus. METHODS: A series of six cases of humeral tumour treated by a single surgeon in a single centre was reviewed after a mean follow-up of 5.9 years. The tumours included two chondrosarcomas, one plasmocytoma and three metastases. Resection involved bone epiphysis, metaphysis and diaphysis in five cases (S3S4S5A) and epiphysis and metaphysis in one case (S3S4A). For reconstruction, an allograft composite reverse shoulder arthroplasty was used in all the cases. Outcomes were assessed with range of motion, the QuickDash score and the Short Form 12 (SF-12) Health Survey. Radiographs assessed osseointegration and complications. RESULTS: At the final follow-up, the mean shoulder range of motion were respectively 95°, 57° and 11° for forward flexion, abduction and external rotation. Mean QuickDASH score improved from 28 to 41 and VAS-pain scores improved from 5.1 to 2.3. The post-operative MSTS score was 73% and the Constant score was 46.1/100. The SF-12 PCS and MCS scores were also improved, respectively from 44.4 and 39.7 to 45.5 and 56.1. The mean satisfaction score was 8.1/10. CONCLUSIONS: Composite reverse shoulder arthroplasty is a viable alternative for reconstruction after resection of malignant humeral tumour. Although total tumour resection was the most important objective, the functional and quality of life scores were satisfactory.

Treatment of Massive Irreparable Rotator Cuff Tears: A Cost-effectiveness Analysis.

Massive irreparable rotator cuff tears cause significant shoulder pain and dysfunction. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and hemiarthroplasty (HA) are treatments shown to reduce pain and improve quality of life. Reverse total shoulder arthroplasty (RTSA) is a newer surgical treatment option that may offer improved function. A cost-effectiveness analysis of these interventions has never been performed, and no head-to-head comparative effectiveness trials currently exist. A Markov decision analytic model was used to compare RTSA, HA, AD-BT, and PT as treatments for elderly patients with massive irreparable rotator cuff tears. Probabilities for complications, perioperative death, conversion procedures, and reoperations were derived from the literature, and costs were determined by average Medicare reimbursement rates from 2011. Reverse total shoulder arthroplasty yielded the most quality-adjusted life years (QALY) with 7.69, but greater benefits came at higher costs compared with other treatments. Sensitivity analyses showed that PT was the most cost-effective intervention at a health utility of 0.75 or greater (QALY 7.35). The health utility of RTSA was 0.72 or less (QALY 7.48) or RTSA probability of no complications was 0.83 or less (QALY 7.48 at cost of $23,830). Reverse total shoulder arthroplasty yielded benefits at a cost considered good value for money compared with other treatments. Reverse total shoulder arthroplasty is the preferred and most cost-effective treatment option for elderly patients with massive irreparable rotator cuff tears. For patients seeking pain relief without functional gains, AD-BT can be considered a cost-effective and cheaper alternative. The cost-effectiveness analysis approach can help guide clinical practice as well as the policies of health care systems and insurers. [Orthopedics. 2017; 40(1):e65-e76.].