Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness. METHODS: The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period. RESULTS: A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively. CONCLUSIONS: The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Anatomic TSA for B2 glenoids treated with asymmetric reaming has equivalent survivorship and patient outcomes compared to type A glenoids at mean 9 years follow-up.

BACKGROUND: Walch B2 glenoids can present a challenge to shoulder arthroplasty surgeons. Short-term studies have demonstrated that corrective reaming to 10° of retroversion in anatomic total shoulder arthroplasty (aTSA) can result in good outcomes, however there is little data reporting the long-term outcomes in this cohort. B2 glenoids treated with high-side reaming present a theoretical risk of early glenoid component failure as one may ream into the subchondral bone. This study aimed to demonstrate that 1) B2 glenoids treated with corrective reaming have durable results and 2) offer similar results to Walch A1/2 in long-term follow-up. METHODS: Patients who underwent aTSA by a single surgeon (E.L.F.) were identified from a shoulder arthroplasty registry. Inclusion criteria included Walch A1, A2 or B2 glenoid, a diagnosis of primary shoulder osteoarthritis, and a minimum radiographic and clinical follow-up of 5 years. 43 patients with B2 glenoids were compared to a cohort of 42 patients with A1 or A2 glenoids. Preoperative computed tomography (CT) and radiographs were utilized to assess deformity, glenoid version, and posterior subluxation of the humeral head. Postoperatively, patients were assessed with radiographs and patient-reported outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and Visual Analog Scale (VAS). RESULTS: 85 shoulders (82 patients, 42 B2 and 43 A1/A2 glenoids) with an average follow-up of 9.4 years were included. In the B2 cohort, the average retroversion was 21.1° and posterior subluxation was 69.4% compared with 10.6°(p<0.001) and 57.5% (p<0.001) in the A1 or A2 cohort. The cohort demographics were similar except for male sex (B2 69.8% vs A1 or A2 37.2%, p=0.008). There was no difference between the cohorts in their improvement in ASES (p=0.807), SST (p=0.586), or VAS (p=0.930) scores. There was no difference in lateral humeral offset (p=0.889) or acromial humeral interval (p=0.468) between initial postoperative and final follow-up visits. Survivorship for B2 glenoids was 97.6%, 94.1% and 73.3% at 5, 10 and 15 years, respectively compared to 97.6%, 91.9% and 83.5% in type A glenoids. The revision rate was similar between the two groups (p=0.432). Lazarus score (p=0.682) and rates of humeral radiolucency (p=0.366) and humeral osteolysis (p=0.194) were similar between the two cohorts at final follow-up. CONCLUSION: Asymmetric reaming of patients with B2 glenoids is a reliable method of glenoid preparation with excellent mid- to long-term clinical results, patient reported outcomes, and low revision rates similar to their A1 and A2 counterparts.

Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients.

BACKGROUND: Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS: This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS: Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.

Cemented vs. press-fit humeral stems: a matched cohort analysis at a mean follow-up of 10 years.

BACKGROUND: Although cementation of humeral stems has long been considered the gold standard for anatomic shoulder arthroplasty (aTSA), cementless, or press-fit, fixation offers a relatively cheaper and less demanding alternative, particularly in the setting of a revision procedure. However, this approach has been accompanied by concerns of implant loosening and high rates of radiolucency. In the present study, we performed a propensity-matched comparison of clinical and patient-reported outcomes between cemented and cementless fixation techniques for aTSA. We hypothesized that cemented fixation of the humeral component would have significantly better implant survival while providing comparable functional outcomes at final follow-up. METHODS: This study was a retrospective comparison of 50 shoulders undergoing aTSA: 25 using cemented humeral fixation vs. 25 using press-fit humeral fixation. Patients in the 2 groups were propensity matched according to age, sex, and preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. Primary outcome measures included range of motion (ROM) (forward elevation, external rotation, internal rotation), patient-reported outcomes (ASES, Simple Shoulder Test [SST], visual analog scale [VAS]), and implant survival. RESULTS: At baseline, the 2 fixation groups were similar in regard to age, sex, body mass index, preoperative ASES score, and surgical indication. Mean follow-up was 11.7 ± 4.95 years in the cemented cohort and 9.13 ± 3.77 years in the press-fit cohort (P = .045). Both groups demonstrated significant improvements postoperatively in all included ROM and patient-reported outcomes. However, press-fit patients reported significantly better VAS, ASES, and SST scores. Mean VAS pain score was 1.1 ± 1.8 in press-fit patients and 3.2 ± 3.0 in cemented patients (P = .005). The mean ASES score was 87.7 ± 12.4 in press-fit patients and 69.5 ± 22.7 in cemented patients (P = .002). Lastly, the mean SST score was 9.8 ± 3.1 in press-fit patients and 7.7 ± 3.7 in cemented patients (P = .040). Both fixation techniques provided lasting implant survivorship with only a single revision operation in each of the cohorts. CONCLUSION: Herein, we provide a propensity-matched, long-term comparison of patients receiving anatomic shoulder arthroplasty stratified according to humeral stem fixation technique. The results of this analysis illustrate that both types of humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up.

Mid-term outcomes following reverse total shoulder arthroplasty.

PURPOSE: The utilization of reverse total shoulder arthroplasty now exceeds the incidence of anatomic shoulder arthroplasty. Previous mid-to-long-term studies on rTSA have reported a decrease in shoulder function as follow-up increased. The purpose of this study was to provide data on mid-term outcomes and implant survival in a series focusing on reverse total shoulder arthroplasty. MATERIALS AND METHODS: Demographic information such as age at surgery, revision surgery status, BMI, and smoking status were recorded. The clinical endpoints measured in this study were range of motion scores (forward elevation, external rotation, internal rotation) and patient reported outcomes (VAS, ASES, SST). Radiographic variables captured included preoperative glenoid morphology, humeral lucency, and glenoid loosening. RESULTS: Fifty-six shoulders were included in this study. The overall mean age at surgery was 72.5 ± 7.2 years with an average follow-up time of 6.8 ± 3.5 years. The mean BMI was 28.1 ± 5.5. All measurements of range of motion saw significant and sustained improvements. Overall, forward elevation improved from 82° preoperatively to 133° postoperatively (p < 0.01). External rotation improved from 23° preoperatively to 36° (p < 0.01), while internal rotation improved from L3 to L1 (p = 0.05). ASES scores improved from 31 preoperatively to 70 postoperatively (p < 0.01). SST scores improved from 2 preoperatively to 7 (p < 0.01). VAS pain index scores improved from 6 to 2 following surgery (p < 0.01). Postoperative scapular notching was seen in 18 patients at final follow-up. Glenoid loosening was seen in 3 shoulders. Humeral loosening was seen in 18 shoulders. Tuberosity resorption was seen in 8 shoulders. The 5 year survival estimate was 98%, and the 10 year survival estimate was 83%. CONCLUSION: In this series, we found that rTSA provides mid-term improvements in range of motion in patients while reducing pain levels. When considered together, this demonstrates that most patients undergoing rTSA can have excellent use of their shoulder from age at surgery to end-of-life.

An Assessment of Upper-Extremity Surgical Technique Videos and Their Relationship With Procedural Learning Theory.

PURPOSE: Our purpose was to ascertain how well award-winning and highly viewed upper-extremity surgical videos meet the needs of users and adhere to procedural learning theory. We hypothesized that upper-extremity videos hosted on academic society websites meet user needs better than upper-extremity videos hosted on a commercial website. METHODS: Twenty-five upper-extremity videos were evaluated by 3 reviewers. A standardized scoring sheet was used to assess each video's content, production quality, and adequacy. Video lengths were compared. The inclusion frequencies of specific content categories, the adequacy of content, and meeting certain production standards, all of which assess consistency with procedural learning theory, were reported, stratified by video host. Associations between the video host and video content, production quality, and adequacy were assessed. RESULTS: The median lengths of academically hosted and commercially hosted videos were similar. Regardless of the video host, no video contained information in all content categories. Sixty percent of the scored categories were present in less than 75% of evaluated videos. Academically hosted videos contained scored content more frequently than commercially hosted videos in 68.4% of categories. There were significant associations between academic hosts and inclusion of a case presentation, surgical indications, outcomes literature, a preoperative examination, follow-up visit intervals, and alternative surgical techniques. Overall, academically hosted videos had a higher percentage of adequate content categories compared with commercially hosted videos. CONCLUSIONS: Videos on academic websites more consistently meet users' content needs and production expectations, as informed by procedural learning theory, while having higher rates of adequate content compared with videos on commercial websites. CLINICAL RELEVANCE: While academically hosted videos appear to more consistently adhere to the tenets of procedural learning theory, opportunity exists for video creators to more consistently apply procedural learning theory, allowing for the creation of even more educationally beneficial online surgical videos.

Second Harmonic Generation Microscopy as a Novel Intraoperative Assessment of Rat Median Nerve Injury.

PURPOSE: Nerves that are functionally injured but appear macroscopically intact pose the biggest clinical dilemma. Second Harmonic Generation (SHG) Microscopy may provide a real-time assessment of nerve damage, with the ultimate goal of allowing surgeons to accurately quantify the degree of nerve damage present. The aim of this study was to demonstrate the utility of SHG microscopy to detect nerve damage in vivo in an animal model. METHODS: Ten Sprague-Dawley rats were anesthetized and prepared for surgery. After surgical exposure and using a custom-made stretch applicator, the right median nerves were stretched by 20%, corresponding to a high strain injury, and held for 5 minutes. The left median nerve served as a sham control (SC), only being placed in the applicator for 5 minutes with no stretch. A nerve stimulator was used to assess the amount of stimulation required to induce a flicker and contraction of the paw. Nerves were then imaged using a multiphoton laser scanning microscope. RESULTS: Immediately after injury (day 0), SHG images of SC median nerves exhibited parallel collagen fibers with linear, organized alignment. In comparison with SC nerves, high strain nerves demonstrated artifacts indicative of nerve damage consisting of wavy, undulating fibers with crossing fibers and tears, as well as a decrease in the linear organization, which correlated with an increase in the mean stimulation required to induce a flicker and contraction of the paw. CONCLUSIONS: Second Harmonic Generation microscopy may provide the ability to detect an acute neural stretch injury in the rat median nerve. Epineurial collagen disorganization correlated with the stimulation required for nerve function. CLINICAL RELEVANCE: In the future, SHG may provide the ability to visualize nerve damage intraoperatively, allowing for better clinical decision-making. However, this is currently a research tool and requires further validation before translating to the clinical setting.

Does body mass index influence long-term outcomes after anatomic total shoulder arthroplasty?

BACKGROUND: As of 2018, upwards of 42% of the US adult population was considered obese based on body mass index (BMI) scales. With the annual number of total joint replacements increasing, this study aimed to evaluate the impact BMI has on anatomic total shoulder arthroplasty (aTSA) outcomes. METHODS: This was a retrospective analysis of 128 shoulders requiring primary aTSA. Patients were stratified into 3 cohorts based on their BMI at surgery: underweight/normal weight (U/NW; BMI ≤25.0), overweight (25.0 < BMI ≤ 30.0), and obese (BMI >30.0). BMI was separately analyzed as a continuous variable. Clinical endpoints were range of motion scores, including forward elevation, external rotation, and internal rotation, and patient-reported outcomes, including visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, and the Simple Shoulder Test (SST). Survivorship curves were calculated using Kaplan-Meier analysis. RESULTS: Forty-four, 50, and 34 patient shoulders were in the U/NW, overweight, and obese cohorts, respectively. The mean follow-up time was 11.4 years. The U/NW cohort had more females (73%) compared with the overweight (34%; P = .0030) and obese (35%; P = .0015) groups; no differences were seen in revision rates. BMI was negatively correlated with age at surgery (r = -0.19, P = .014); it was not correlated with any of the 6 postoperative clinical endpoints. All 3 cohorts saw significant improvements in forward elevation, external rotation, internal rotation and VAS, ASES, and SST scores when compared preoperatively to postoperatively (P < .001). There were no significant differences between the 3 cohorts with respect to postoperative range of motion. Postoperative ASES scores were higher for the overweight cohort (82.6 ± 18.6) compared with both the U/NW (63.0 ± 25.1) and obese cohorts (70.5 ± 26.8) (P < .001). The overweight cohort also had higher SST (P = .0012) postoperative scores compared with the U/NW and obese cohorts; VAS scores were comparable between groups (P = .12). The nonobese (BMI <30) group (n = 94) showed 5-, 10-, and 15-year implant survival of 98.9%, 94.9%, and 83.9%, respectively compared to 97.1%, 93.7%, and 87.0% in the obese (BMI ≥30) group (n = 34). The log rank test revealed no significant difference in survival curves (P = .82). CONCLUSION: To our knowledge, this is the longest follow-up study analyzing clinical endpoints stratified by BMI for aTSA. We saw that patients with a higher BMI required shoulder replacement at a significantly younger age. However, we also report that regardless of BMI, all patients saw significant improvements in patient-reported outcomes and range of motion scores postoperatively.

Superior migration of the humeral head does not significantly affect outcomes at an average of 11 years after total shoulder arthroplasty.

BACKGROUND: Superior migration of the humeral head has been linked with rotator cuff dysfunction and glenoid loosening after total shoulder arthroplasty (TSA). We aimed to determine if superior migration was associated with poor shoulder function following anatomic TSA at long-term follow-up. METHODS: In this retrospective cohort study, we reviewed patients undergoing TSA by a single surgeon at an urban, academic institution. To study the effect of superior migration on TSA outcomes, we stratified the cohort by ≥ and <7 mm of acromiohumeral interval (AHI) and compared range of motion and patient reported outcomes (PROs). Clinical variables included preoperative and postoperative forward elevation (FE), internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, and Simple Shoulder Text score. Radiographic variables included immediate postoperative and long-term follow-up AHI, lateral humeral offset, and glenoid loosening scores. RESULTS: After applying exclusion criteria, 121 TSAs were included. The mean age was 63.9 ± 9.5 years, and 66 surgeries (55%) were in male patients. The mean follow-up for our cohort was 11.2 years (range, 5-26 years). Nine shoulders underwent revision surgery. All range of motion and PROs improved significantly from preoperative to the most recent postoperative follow-up. The mean AHI immediately following surgery was 10.9 ± 4.1 mm, while the mean AHI at most recent follow-up was 8.4 ± 3.5 mm. Glenoid loosening was observed in 29 (23.8%) shoulders at the most recent follow-up appointment. Although AHI correlated weakly with FE (r = 0.252; P = .006), we did not observe a clear threshold of migration which led to degraded function. Importantly, glenoid loosening was not related to AHI at long-term follow-up (P = .631). None of FE, internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, Simple Shoulder Text, or revisions were significantly different between patients with ≥ and <7 mm of AHI. CONCLUSION: Our results suggest that anatomic TSA provides durable improvements to pain, function, and PROs despite changes to the AHI.

Long-term clinical and radiographic outcomes of total shoulder arthroplasty in patients under age 60 years.

BACKGROUND: We aimed to characterize the long-term clinical and radiographic outcomes of total shoulder arthroplasty (TSA) in patients aged < 60 years. We hypothesized meaningful improvements in shoulder functionality and pain with TSA and an acceptably low rate of prosthesis complications and revisions. METHODS: This was a retrospective cohort study of 29 patients (34 shoulders) undergoing TSA before age 60 years with a minimum follow-up period of 10 years. Shoulder range of motion, functionality (American Shoulder and Elbow Surgeons and Simple Shoulder Test scores), and pain (visual analog scale score) were evaluated. Radiographs were assessed for lateral humeral offset, the acromiohumeral interval, and glenoid loosening. RESULTS: The mean age of the patients was 54.4 ± 5.5 years (range, 35.5-59.8 years), with a mean follow-up period of 16.1 ± 4.5 years (range, 10.0-26.1 years). In patients aged < 60 years, TSA significantly improved forward elevation (from 119° ± 26° to 146° ± 21°, P = .0002), external rotation (from 21° ± 25° to 52° ± 15°, P = .0001), and internal rotation (from L5 to L1, P = .002). Additionally, TSA significantly increased American Shoulder and Elbow Surgeons scores (from 32 ± 20 to 64 ± 27, P = .0008) and Simple Shoulder Test scores (from 3 ± 2 to 7 ± 4, P = .0004) and reduced visual analog scale pain scores (from 7 ± 3 to 3 ± 3, P = .0001). Radiographically, there was no significant difference in mean lateral humeral offset (13 ± 6 mm vs. 10 ± 12 mm, P = .472) or the mean acromiohumeral interval (20 ± 4.2 mm vs. 16 ± 6 mm, P = .061) between immediate postoperative and final follow-up radiographs. Radiographic evidence of glenoid loosening was noted in 2 patients. Complications occurred in 6 patients (17.6%), all of which were cases of aseptic glenoid loosening. Ultimately, 4 patients underwent conversion to a reverse TSA and 2 underwent arthroscopic glenoid removal. The rate of prosthesis survivorship was 97.1% (95% confidence interval [CI], 91.4%-100%) at 10 years, 85.4% (95% CI, 73.7%-97.2%) at 15 years, and 80.1% (95% CI, 65.1%-98.4%) at 20 years. DISCUSSION: TSA consistently improved shoulder functionality and reduced pain while limiting the need for further revisions. These findings suggest that TSA is a viable treatment option for glenohumeral arthritis in younger patients.

Survivorship of total shoulder arthroplasty vs. hemiarthroplasty for the treatment of avascular necrosis at greater than 10-year follow-up.

BACKGROUND: Avascular necrosis (AVN) of the humeral head is a debilitating pathology that can be managed with an array of treatments depending on disease staging. Humeral head arthroplasty for AVN has demonstrated good short-term improvements in pain and range of motion, but the published long-term outcomes data are limited. The objective of this study was to report long-term survivorship and outcomes for patients undergoing hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for the treatment of AVN of the humeral head. METHODS: The practice of one fellowship-trained shoulder surgeon was queried for the surgical treatment of AVN of the humeral head via appropriate International Classification of Diseases, Ninth and Tenth Revision, codes. Sixteen shoulders that met inclusion criteria were identified. Demographics included the radiographic stage, age, sex, American Society of Anesthesiologists (ASA) score, and body mass index. The primary endpoint was survivorship of the implant. Secondary endpoints were range of motion in forward elevation, internal and external rotation, visual analog scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Simple Shoulder Test score. RESULTS: Of the 16 shoulders included in the study, 10 underwent HA and 6 underwent TSA. The TSA cohort was significantly older (mean 60.5 vs. 44.2, P = .005), with a higher mean ASA score (mean 3.0 vs. 2.13, P = .02) than the HA group. The 10-year survivorship rates were 88.9% for HA and 80% for TSA with no significant difference between groups. Survivorship data were available for a mean 13.0 ± 5.6 years' follow-up in the HA group and 13.8 ± 4.8 years in the TSA group. When compared to one another, the results between HA and TSA only differed in internal rotation, which was statistically significantly improved in the TSA group compared with HA (2.3 ± 2.6 compared with -3.0 ± 5.0, P = .03). CONCLUSION: The survivorship of both TSA and HA for the treatment of AVN was at least 80% at 10 years. Secondary endpoints, such as range of motion, pain, and shoulder function, improved significantly postoperatively in each cohort and were similar between the 2 groups, except for internal rotation, which had improved significantly more in the TSA group than in HA. Both TSA and HA are viable options for the treatment of AVN, each with durable long-term survival.

Experience Level Influences Users' Interactions With and Expectations For Online Surgical Videos: A Mixed-Methods Study.

PURPOSE: Upper-extremity surgeons and trainees widely use online surgical videos, and the use of these videos can assist with procedural learning. The purpose of this study was to characterize online video use and understand the role videos play in the learning process of orthopedic residents and practicing surgeons. We hypothesized that the use of surgical videos and video content desired among orthopedic learners differs based on their experience level. METHODS: Four focus groups were conducted to discuss online surgical videos and their role in the learning process of orthopedic learners. Participants were separated based on their experience level. Three reviewers qualitatively analyzed the transcripts of the focus groups using constant comparative methods to identify overarching themes and categories. Findings regarding the participants' desires for video content and production quality were translated into a survey. The survey results were analyzed to assess their associations with experience level. RESULTS: The focus group analysis helped identify 4 overarching themes that reflected users' interactions with videos: prewatching experience, choosing a video, video use, and video design, with the users' comments differing based on their experience level. The survey results showed that the median ideal length for a video was 10 minutes and that all users, regardless of their experience level, ranked showing the surgical procedure as the most important part of a video. Junior residents more frequently desired background information and a written outline of surgical steps, whereas more senior learners placed greater emphasis on advanced surgical decision-making and the use of particular implants/devices. CONCLUSIONS: Experience level influences users' interactions with videos, including how they are chosen and used, and their expectations in terms of content and production. CLINICAL RELEVANCE: Video creators should specify their targeted audience's experience level and adjust content to meet users' needs. Our results can provide video creators and hosts a checklist for appropriate content and production standards.

Comparison of machine learning techniques to predict unplanned readmission following total shoulder arthroplasty.

BACKGROUND: Machine learning (ML) techniques have been shown to successfully predict postoperative complications for high-volume orthopedic procedures such as hip and knee arthroplasty and to stratify patients for risk-adjusted bundled payments. The latter has not been done for more heterogeneous, lower-volume procedures such as total shoulder arthroplasty (TSA) with equally limited discussion around strategies to optimize the predictive ability of ML algorithms. The purpose of this study was to (1) assess which of 5 ML algorithms best predicts 30-day readmission, (2) test select ML strategies to optimize the algorithms, and (3) report on which patient variables contribute most to risk prediction in TSA across algorithms. METHODS: We identified 9043 patients in the American College of Surgeons National Surgical Quality Improvement Database who underwent primary TSA between 2011 and 2015. Predictors included demographics, comorbidities, laboratory data, and intraoperative variables. The outcome of interest was 30-day unplanned readmission. Five ML algorithms-support-vector machine (SVM), logistic regression, random forest (RF), an adaptive boosting algorithm, and neural network-were trained on the derivation cohort (2011-2014 TSA patients) to predict 30-day unplanned readmission rates. After training, weights for each respective model were fixed and the classifiers were evaluated on the 2015 TSA cohort to simulate a prospective evaluation. C-statistic and f1 scores were used to assess the performance of each classifier. After evaluation, features were removed independently to assess which features most affected classifier performance. RESULTS: The derivation and validation cohorts comprised 5857 and 3186 primary TSA patients, respectively, with similar demographics, comorbidities, and 30-day unplanned readmission rates (2.9% vs. 2.7%). Of the ML algorithms, SVM performed the worst with a c-statistic of 0.54 and an f1-score of 0.07, whereas the random-forest classifier performed the best with the highest c-statistic of 0.74 and an f1-score of 0.18. In addition, SVM was most sensitive to loss of single features, whereas the performance of RF did not dramatically decrease after loss of single features. Within the trained RF classifier, 5 variables achieved weights >0.5 in descending order: high bilirubin (>1.9 mg/dL), age >65, race, chronic obstructive pulmonary disease, and American Society of Anesthesiologists' scores ≥3. In our validation cohort, we observed a 2.7% readmission rate. From this cohort, using the RF classifier we were then able to identify 436 high-risk patients with a predicted risk score >0.6, of whom 36 were readmitted (readmission rate of 8.2%). CONCLUSION: Predictive analytics algorithms can achieve acceptable prediction of unplanned readmission for TSA with the RF classifier outperforming other common algorithms.

Administration of tranexamic acid during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events.

INTRODUCTION: Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in various orthopedic surgeries including shoulder arthroplasty. However, concerns still exist regarding its use in patients with a history of thrombotic events. Using national claims data, we aimed to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events. METHODS: We used retrospective national claims data (Premier Healthcare) on 71,174 patients who underwent a total or reverse shoulder arthroplasty between 2010 and 2016. TXA use was evaluated specifically within a subgroup of patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. Studied outcomes were blood transfusion need, complications (including acute renal failure, new onset myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke), and cost and length of hospitalization. Mixed-effects models measured the association between TXA use and outcomes, separately in patients with and without a history of thrombotic events. Odds ratios (OR) or percent change for continuous outcomes with 95% confidence intervals (CI) were reported. RESULTS: Overall, TXA was used in 13.7% (n = 9735) of patients, whereas 10.5% (n = 7475) of patients had a history of a thrombotic event. After adjustment for relevant covariates, TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48; CI, 0.24-0.98; P = .0444), whereas no increased odds for complications were observed (OR, 0.83; CI, 0.40-1.76; P = .6354). Similar results were observed in patients with a history of thrombotic events. Moreover, in this subgroup, TXA use was associated with a slight reduction in hospitalization cost (-8.9% CI: -13.1%; -4.6%; P < .0001; group median $18,830). CONCLUSIONS: Among shoulder arthroplasty patients, TXA use was not associated with increased complication odds, independent of a history of thrombotic events. These findings are in support of wider TXA use.

Revision rotator cuff repair: a systematic review.

BACKGROUND: The incidence of revision rotator cuff repair (RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes. METHODS: The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (rs). RESULTS: A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (rs = 0.98). A strong positive correlation was also found between mean preoperative forward flexion and mean postoperative forward flexion (rs = 0.83). The mean preoperative VAS pain score was strongly correlated with the mean postoperative VAS pain score (rs = 0.88) and demonstrated a moderate negative association with the mean postoperative ASES score (rs = -0.48). Finally, the mean preoperative ASES score was moderately correlated with the mean postoperative ASES score (rs = 0.56). CONCLUSIONS: The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Retrospective review of open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement: a single surgeon's experience.

BACKGROUND: There have been conflicting results when comparing outcomes of open vs. arthroscopic anterosuperior rotator cuff repairs with subscapularis involvement. The purpose of this study was to evaluate midterm outcome differences and complications following open vs. arthroscopic repair of rotator cuff tears involving the subscapularis by a single surgeon. METHODS: This was a retrospective review of 57 rotator cuff repairs involving the subscapularis performed by a single surgeon over a 10-year period. During this time, the surgeon transitioned from open to arthroscopic repair. Preoperative and postoperative range of motion, lift-off test, belly press test, and American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment form scores were measured. RESULTS: Eighteen patients had open procedures and 39 had arthroscopic repair. The mean preoperative ASES score for the open group was 39 and postoperatively was 79. The mean preoperative ASES score for the arthroscopic group was 44 and improved to 80 postoperatively. There was no significant difference in score or change in score between the 2 groups (P > .05). There was only 1 complication. It occurred in the open group and was a superficial wound dehiscence. CONCLUSIONS: This study demonstrated no outcome differences between open and arthroscopic rotator cuff repair involving the subscapularis, even with large subscapularis tears. Both techniques significantly improved shoulder function. Arthroscopic and open rotator cuff repairs including the subscapularis are relatively safe procedures, and either technique is an acceptable option.

Drain Use is Associated with Increased Odds of Blood Transfusion in Total Shoulder Arthroplasty: A Population-Based Study.

BACKGROUND: In the absence of evidence supporting its benefit, the American Academy of Orthopaedic Surgeons (AAOS) strongly recommends against closed wound drainage in TKA; however, drain usage remains common in other joints, including the shoulder. While an extensive body of research exists for drain use in lower extremity joint arthroplasty, large-scale data on drain use and its association with benefits and complications in shoulder arthroplasties is lacking. Such data may be particularly valuable given the rapidly increasing demand for shoulder arthroplasties. QUESTION/PURPOSE: Using national claims data, we (1) evaluated the trends in frequency of drain usage in shoulder arthroplasty procedures over time, as well as the association between drain usage and (2) blood transfusion usage, (3) length of stay (LOS), and (4) readmission or early infection within 30 days. METHODS: This retrospective study used data from the nationwide Premier Healthcare claims database (2006-2016; n = 105,116, including total, reverse, and partial shoulder arthroplasties, in which drains were used in 20% [20,886] and no drain was used in 80% [84,230]). Included hospitals were mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). The Premier database contains detailed inpatient billing data on approximately 20% to 25% of US hospital discharges, which allows the creation of a variable indicating drain use by evaluating inpatient billing for drains. Baseline demographics differed minimally between patients receiving a drain compared with those who did not, with a median age of 70 years in both groups. The potential for selection bias was addressed by adjusting for measured confounders in mixed-effects models that estimated associations between drain use and blood transfusion usage, LOS, and readmission or (early) infection within 30 days. In addition, alternative statistical approaches were applied to address confounding, including propensity score analysis and instrumental variable analysis where a so-called "instrumental variable" is applied that mimics the treatment assignment process similar to a randomized study. We report odds ratios (OR; or % change for continuous variables) and 95% confidence intervals (CIs). RESULTS: The usage of drains decreased over time, from 1106 of 4503 (25%) in 2006 to 2278 of 14,501 (16%) in 2016. After adjusting for relevant covariates, drain use was associated with an increased usage of blood transfusions (OR, 1.49; 95% CI, 1.35-1.65; p < 0.001) while only associated with a small increase in LOS (+6%, 95% CI, +4% to +7%; p < 0.001). Drain use was not associated with increased odds for early postoperative infection or 30-day readmission. Propensity score analysis and instrumental variable analysis corroborated our main results. CONCLUSIONS: Use of drains in patients undergoing shoulder arthroplasty is associated with an almost 50% increased odds for blood transfusions. Given that our findings parallel close to what is known in patients undergoing lower extremity joint arthroplasty, we believe that our results from a large national database are sufficient to discourage the routine use of drains in patients undergoing shoulder arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study.

Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To evaluate the preliminary clinical outcomes and complications of superior capsule reconstruction (SCR) for irreparable rotator cuff tears. METHODS: A systematic review of PubMed, MEDLINE, EMBASE, and Cochrane databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical outcomes of irreparable rotator cuff tears managed by SCR were included. Clinical outcome analyses of pre- and postoperative range of motion, American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, and acromiohumeral intervals (AHIs) were performed and reported as range or frequency. RESULTS: Five studies (285 patients, 291 shoulders) of level III-IV evidence were included, with a weighted mean (± standard deviation) follow-up of 27.7 ± 17.3 months. Forward flexion improved from 91°-130° preoperatively to 147°-160° postoperatively, external rotation from 26°-41° to 41°-45°, and internal rotation from L4-L1 to L1. American Shoulder and Elbow Surgeons scores increased from 36-52.2 to 77.5-92, and visual analog scale pain scores decreased from 4.0-6.3 to 0.4-1.7. Radiographically, AHIs with acellular dermal allograft ranged from 4.5 to 7.1 mm preoperatively, improving to 7.6-10.8 mm immediately postoperation before decreasing to 6.7-9.7 mm by final follow-up. Complication and graft failure rates were 17.2% and 11.7%, respectively. CONCLUSIONS: Preliminary results of SCR show consistent improvement in shoulder functionality and pain reduction. However, a decrease in postoperative AHIs indicates dermal allograft elongation and persistent superior migration of the humerus, potentially contributing to later graft failure. Studies with longer follow-up will be essential to evaluate the long-term utility of SCR in the treatment of irreparable rotator cuff tears. LEVEL OF EVIDENCE: Level IV, systematic review of level III-IV studies.

Acromial spine fracture after reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) accounts for nearly one-third of shoulder arthroplasty utilization nationally. The complication rate has increased concurrently. Consensus is lacking regarding the incidence, etiology, and treatment of acromial or scapular spine fractures after RSA. The purpose of our study was to perform a systematic review of the literature to analyze the occurrence and outcomes of this complication. METHODS: The MEDLINE, Embase, Google Scholar, and Cochrane databases were queried in late 2017 for combinations of the words "acromial," "fracture," "reverse," "shoulder," and "arthroplasty." We included all studies that contained a clearly defined performance of RSA, acromial fracture(s) noted, and treatment (if any) and outcomes of treatment. The initial search yielded 50 studies; 32 met the inclusion criteria. RESULTS: Among 3838 RSAs, 159 acromial fractures were reported, for an overall incidence of 4.14%; the mean time to diagnosis from surgery was 9 months (range, 1.3-24 months). Treatments included nonoperative treatment in a sling or abduction brace in 139 cases and open reduction-internal fixation in 20. Regardless of treatment, patients reported inferior function after fracture compared with initially after RSA. Forward flexion was 95° (range, 30°-110°), abduction was 76° (range, 30°-180°), the Constant score was 63 (range, 59-67.5), and the American Shoulder and Elbow Surgeons score was 57 (range, 7-83); all values were reduced compared with patients without fractures. CONCLUSION: This study suggests the occurrence of acromial fractures after RSA is a common event, with a rate of over 4%. These fractures correlate with worse postoperative outcomes regardless of treatment method; open reduction-internal fixation was not shown to be clinically superior despite a limited complication rate. Additional high-quality studies addressing acromial spine fracture after RSA are needed.

Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study.

BACKGROUND: Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension. METHODS: Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks. RESULTS: The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone. CONCLUSION: A branch of the anterior humeral circumflex is a reliable landmark for identifying the mid-suprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis.