High pain intensity after total shoulder arthroplasty.

BACKGROUND: As reimbursement becomes increasingly tied to quality and patient experience, there is growing interest in alleviation of postoperative pain combined with optimal opioid stewardship. We characterized predictors of severe inpatient pain after elective total shoulder arthroplasty and evaluated its association with opioid use, operative time, hospital length of stay, discharge disposition, and cost. METHODS: We identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017 from our registry. Severe postoperative pain was defined as peak pain intensity ≥75th percentile. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with severe pain, including demographics, emotional health, comorbidities, and American Shoulder and Elbow Surgeons score. Opioid consumption was expressed as oral morphine equivalents (OMEs). Costs were calculated using time-driven activity-based costing. RESULTS: In decreasing order of magnitude, the predictors of severe postoperative pain were greater number of self-reported allergies, preoperative chronic opioid use, lower American Shoulder and Elbow Surgeons score, and depression. Patients reporting severe pain took more opioids (202 vs. 84 mg OMEs), stayed longer in the hospital (2.9 vs. 2.0 days), used postacute inpatient rehabilitation services more frequently (28% vs. 10%), and were more likely to be high-cost patients (23% vs. 5%; all P < .001), but they did not have longer operations (166 vs. 165 minutes, P = .86). CONCLUSIONS: Efforts to address psychological and social determinants of health might do as much or more than technical improvements to alleviate pain, limit opioid use, and contain costs after shoulder arthroplasty. These findings are important in the redesign of care pathways and bundling initiatives.

Lateralization of the glenosphere in reverse shoulder arthroplasty decreases arm lengthening and demonstrates comparable risk of nerve injury compared with anatomic arthroplasty: a prospective cohort study.

HYPOTHESIS: Grammont-style reverse shoulder arthroplasty (RSA) has an increased risk of nerve injury compared with anatomic total shoulder arthroplasty (TSA) due to arm lengthening. We hypothesized that an RSA with a lateralized glenosphere and 135° neck-shaft angle would reduce humeral lengthening and decrease the risk of nerve injury to the level of a TSA. METHODS: The study prospectively enrolled 50 consecutive patients undergoing RSA (n = 30) or TSA (n = 20) as determined by a power analysis based on previous research for our institution. Intraoperative neuromonitoring was used to detect nerve alerts during 4 distinct stages of the procedure. Preoperative and postoperative arm lengths were measured on scaled radiographs. Patients were examined immediately postoperatively and at follow-up visits for neurologic complications. RESULTS: Mean motor and sensory nerve alerts per case were similar for TSA and RSA (motor: TSA, 1.5 ± 2; RSA, 1.5 ± 2; P = .96; sensory: TSA, 0.6 ± 0.9; RSA, 0.2 ± 0.6; P = .06). The mean change in arm length was 3 ± 7 mm in the TSA cohort vs. 14 ± 7 mm in the RSA cohort (P = .0001). Temporary neurologic changes postoperatively were noted in 1 TSA and 1 RSA patient, amounting to a 4% incidence of nerve injury. CONCLUSIONS: An RSA design with a lateralized glenosphere and a lower neck-shaft angle decreases arm lengthening compared with the Grammont design. The reduction in lengthening appears to eliminate the historically increased risk of neurologic injury associated with RSA relative to TSA.

Computed tomography underestimates rotator cuff pathology in patients with glenohumeral osteoarthritis.

BACKGROUND: Computed tomography (CT) is the standard assessment of glenoid morphology before shoulder arthroplasty and is commonly used to evaluate rotator cuff pathology in patients with glenohumeral osteoarthritis (GHOA). Magnetic resonance imaging (MRI) is not routinely used in this setting but has higher sensitivity in diagnosing full-thickness rotator cuff tears (RCT) and is considered the gold standard. The purpose of this study was to determine the sensitivity and specificity of CT in diagnosing full-thickness RCTs and compare the evaluation of fatty infiltration and muscle atrophy on CT vs. MRI in the setting of GHOA. METHODS: In this retrospective case-controlled study, we identified 49 patients from a prospectively maintained 2-surgeon registry who received preoperative CT and MRI scans for the evaluation of GHOA between 2011 and 2016. Three fellowship-trained shoulder surgeons assessed rotator cuff integrity, fatty infiltration, and muscle atrophy in the CT and MRI scans. RESULTS: CT sensitivity and specificity were 20% and 95.5%, respectively. Fatty infiltration was significantly lower on CT for the supraspinatus (P = .003), infraspinatus (P < .001), and subscapularis (P = .0182), whereas muscle atrophy was significantly lower on CT for only the supraspinatus (P = .0023). CONCLUSIONS: Our results suggest that CT underestimates the frequency of full-thickness RCTs and the severity of fatty infiltration and muscle atrophy in the setting of GHOA before total shoulder arthroplasty.

Effects of neonatal nutrition interventions on neonatal mortality and child health and development outcomes: A systematic review.

Background: The last two decades have seen a significant decrease in mortality for children <5 years of age in low and middle-income countries (LMICs); however, neonatal (age, 0-28 days) mortality has not decreased at the same rate. We assessed three neonatal nutritional interventions that have the potential of reducing morbidity and mortality during infancy in LMICs. Objectives: To determine the efficacy and effectiveness of synthetic vitamin A, dextrose oral gel, and probiotic supplementation during the neonatal period. Search Methods: We conducted electronic searches for relevant studies on the following databases: PubMed, CINAHL, LILACS, SCOPUS, and CENTRAL, Cochrane Central Register for Controlled Trials, up to November 27, 2019. Selection Criteria: We aimed to include randomized and quasi-experimental studies. The target population was neonates in LMICs. The interventions included synthetic vitamin A supplementation, oral dextrose gel supplementation, and probiotic supplementation during the neonatal period. We included studies from the community and hospital settings irrespective of the gestational age or birth weight of the neonate. Data Collection and Analysis: Two authors screened the titles and extracted the data from selected studies. The risk of bias (ROB) in the included studies was assessed according to the Cochrane Handbook of Systematic Reviews. The primary outcome was all-cause mortality. The secondary outcomes were neonatal sepsis, necrotizing enterocolitis (NEC), prevention and treatment of neonatal hypoglycaemia, adverse events, and neurodevelopmental outcomes. Data were meta-analyzed by random effect models to obtain relative risk (RR) and 95% confidence interval (CI) for dichotomous outcomes and mean difference with 95% CI for continuous outcomes. The overall rating of evidence was determined by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Main Results: Sixteen randomized studies (total participants 169,366) assessed the effect of vitamin A supplementation during the neonatal period. All studies were conducted in low- and middle-income (LMIC) countries. Thirteen studies were conducted in the community setting and three studies were conducted in the hospital setting, specifically in neonatal intensive care units. Studies were conducted in 10 different countries including India (four studies), Guinea-Bissau (three studies), Bangladesh (two studies), and one study each in China, Ghana, Indonesia, Nepal, Pakistan, Tanzania, and Zimbabwe. The overall ROB was low in most of the included studies for neonatal vitamin A supplementation. The pooled results from the community based randomized studies showed that there was no significant difference in all-cause mortality in the vitamin A (intervention) group compared to controls at 1 month (RR, 0.99; 95% CI, 0.90-1.08; six studies with 126,548 participants, statistical heterogeneity I 2 0%, funnel plot symmetrical, grade rating high), 6 months (RR, 0.98; 95% CI, 0.89-1.07; 12 studies with 154,940 participants, statistical heterogeneity I 2 43%, funnel plot symmetrical, GRADE quality high) and 12 months of age (RR, 1.04; 95% CI, 0.94-1.14; eight studies with 118,376 participants, statistical heterogeneity I 2 46%, funnel plot symmetrical, GRADE quality high). Neonatal vitamin A supplementation increased the incidence of bulging fontanelle by 53% compared to control (RR, 1.53; 95% CI, 1.12-2.09; six studies with 100,256 participants, statistical heterogeneity I 2 65%, funnel plot symmetrical, GRADE quality high). We did not identify any experimental study that addressed the use of dextrose gel for the prevention and/or treatment of neonatal hypoglycaemia in LMIC. Thirty-three studies assessed the effect of probiotic supplementation during the neonatal period (total participants 11,595; probiotics: 5854 and controls: 5741). All of the included studies were conducted in LMIC and were randomized. Most of the studies were done in the hospital setting and included participants who were preterm (born < 37 weeks gestation) and/or low birth weight (<2500 g birth weight). Studies were conducted in 13 different countries with 10 studies conducted in India, six studies in Turkey, three studies each in China and Iran, two each in Mexico and South Africa, and one each in Bangladesh, Brazil, Colombia, Indonesia, Nepal, Pakistan, and Thailand. Three studies were at high ROB due to lack of appropriate randomization sequence or allocation concealment. Combined data from 25 studies showed that probiotic supplementation reduced all-cause mortality by 20% compared to controls (RR, 0.80; 95% CI, 0.66-0.96; total number of participants 10,998, number needed to treat 100, statistical heterogeneity I 2 0%, funnel plot symmetrical, GRADE quality high). Twenty-nine studies reported the effect of probiotics on the incidence of NEC, and the combined results showed a relative reduction of 54% in the intervention group compared to controls (RR, 0.46; 95% CI, 0.35-0.59; total number of participants 5574, number needed to treat 17, statistical heterogeneity I 2 24%, funnel plot symmetrical, GRADE quality high). Twenty-one studies assessed the effect of probiotic supplementation during the neonatal period on neonatal sepsis, and the combined results showed a relative reduction of 22% in the intervention group compared to controls (RR, 0.78; 95% CI, 0.70-0.86; total number of participants 9105, number needed to treat 14, statistical heterogeneity I 2 23%, funnel plot symmetrical, GRADE quality high). Authors' Conclusions: Vitamin A supplementation during the neonatal period does not reduce all-cause neonatal or infant mortality in LMICs in the community setting. However, neonatal vitamin A supplementation increases the risk of Bulging Fontanelle. No experimental or quasi-experimental studies were available from LMICs to assess the effect of dextrose gel supplementation for the prevention or treatment of neonatal hypoglycaemia. Probiotic supplementation during the neonatal period seems to reduce all-cause mortality, NEC, and sepsis in babies born with low birth weight and/or preterm in the hospital setting. There was clinical heterogeneity in the use of probiotics, and we could not recommend any single strain of probiotics for wider use based on these results. There was a lack of studies on probiotic supplementation in the community setting. More research is needed to assess the effect of probiotics administered to neonates in-home/community setting in LMICs.

Effect of Synthetic Vitamin A and Probiotics Supplementation for Prevention of Morbidity and Mortality during the Neonatal Period. A Systematic Review and Meta-Analysis of Studies from Low- and Middle-Income Countries.

Background: Suboptimal nutritional status of a newborn is a risk factor for short- and long-term morbidity and mortality. The objectives of this review were to assess the efficacy and effectiveness of neonatal synthetic vitamin A supplementation, dextrose gel and probiotic supplementation for prevention of morbidity and mortality during infancy in low and middle-income countries. Methods: We included randomized trials. Primary outcome was all-cause mortality. We conducted electronic searches on multiple databases. Data were meta-analyzed to obtain relative risk (RR) and 95% confidence interval (CI). Studies for vitamin A and Probiotics were analyzed separately. No studies were found for dextrose gel supplementation during neonatal period. The overall rating of evidence was determined by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Sixteen studies assessed the effect of vitamin A supplementation during the neonatal period. Based on pooled data from community-based studies only, there was no significant effect of vitamin A on all-cause mortality at age 1 month (RR 0.99, 95% CI 0.90, 1.08), 6 months (RR 0.98; 95% CI 0.89-1.08) and 12 months (RR 1.04, 95% CI 0.94, 1.14) but increased risk of bulging fontanelle (RR 1.53, 95% CI 1.12, 2.09). The overall quality of evidence was high for the above outcomes. Thirty-three studies assessed the effect of probiotic supplementation during the neonatal period and were mostly conducted in the hospital setting. Probiotics reduced the risk of all-cause mortality (RR 0.80, 95% CI 0.66, 0.96), necrotizing enterocolitis (RR 0.46, 95% CI 0.35, 0.59) and neonatal sepsis (RR 0.78, 95% CI 0.70, 0.86). The grade ratings for the above three outcomes were high. Conclusions: Vitamin A supplementation during the neonatal period does not reduce all-cause neonatal or infant mortality in low and middle-income countries in the community setting. Probiotic supplementation during the neonatal period seems to reduce all-cause mortality, NEC, and sepsis in babies born low birth weight and/or preterm in the hospital setting.

Negative Patient-Experience Comments After Total Shoulder Arthroplasty.

BACKGROUND: There is growing interest in enhancing the patient experience after discretionary orthopaedic surgery. Patient narratives are a potentially valuable but largely unscrutinized source of information. Using machine learning to understand sentiment within patient-experience comments, we explored the content of negative comments after total shoulder arthroplasty (TSA), their associated factors, and their relationship with traditional measures of patient satisfaction and with perioperative outcomes. METHODS: An institutional registry was used to link the records of 186 patients who had undergone elective primary TSA between 2016 and 2017 with vendor-supplied patient satisfaction data, which included patient comments and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Using a machine-learning-based natural language processing approach, all patient comments were mined for sentiment and classified as positive, negative, mixed, or neutral. Negative comments were further classified into themes. Multivariable logistic regression was employed to determine characteristics associated with providing a negative comment. RESULTS: Most patients (71%) provided at least 1 comment; 32% of the comments were negative, 62% were positive, 5% were mixed, and 1% were neutral. The themes of the negative comments were room condition (27%), time management (17%), inefficient communication (13%), lack of compassion (12%), difficult intravenous (IV) insertion (10%), food (10%), medication side effects (6%), discharge instructions (4%), and pain management (2%). Women and sicker patients were more likely to provide negative comments. Patients who made negative comments were more likely to be dissatisfied with overall hospital care and with pain management (2 HCAHPS core items), but there were no differences in any of the studied outcomes (peak pain intensity, opioid intake, operative time, hospital length of stay, discharge disposition, or 1-year American Shoulder and Elbow Surgeons [ASES] score) between those who provided negative comments and those who did not. CONCLUSIONS: Patient-narrative analysis can shed light on the aspects of the process of care that are most critiqued by patients. While patient satisfaction may not be a surrogate for effectiveness of care or functional outcomes, efforts to improve the hospital environment, enhance nontechnical skills, and reduce unnecessary delays are important in providing high-quality, patient-centered care after TSA.

Delayed hospital discharge after total shoulder arthroplasty: why, and who is at risk?

BACKGROUND: There is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty. METHODS: We retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization. RESULTS: The most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS. CONCLUSIONS: Prolonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

Time-Driven Activity-Based Costing to Identify Patients Incurring High Inpatient Cost for Total Shoulder Arthroplasty.

BACKGROUND: As payment models shift toward a focus on value, an accurate understanding of surgical costs and preoperative correlates of high-cost patients is important for effective implementation of cost-saving strategies. This study used time-driven activity-based costing (TDABC) to explore inpatient cost of total shoulder arthroplasty (TSA) and to identify preoperative characteristics of high-cost patients. METHODS: Using TDABC, we calculated the cost of inpatient care for 415 patients undergoing elective primary TSA between 2016 and 2017. Patients in the top decile of cost were defined as high-cost patients. Multivariable logistic regression modeling was employed to determine preoperative characteristics (e.g., demographics, comorbidities, American Society of Anesthesiologists [ASA] score, and American Shoulder and Elbow Surgeons [ASES] score) associated with high-cost patients. RESULTS: Implant purchase price was the main driver (57%) of total inpatient costs, followed by personnel cost from patient check-in through the time in the operating room (20%). There was a 1.3-fold variation in total cost between patients in the 90th percentile for cost and those in the 10th percentile; the widest cost variation was in personnel cost from the post-anesthesia care unit through discharge (2.5-fold) and in medication cost (2.4-fold). High-cost patients were more likely to be women and chronic opioid users and to have diabetes, depression, an ASA score of ≥3, a higher body mass index (BMI), and a lower preoperative ASES score than non-high-cost patients. After multivariable adjustment, the 3 predictors of high-cost patients were female sex, an ASA score of ≥3, and a lower ASES score. Total inpatient cost correlated strongly with the length of the hospital stay but did not correlate with operative time. CONCLUSIONS: Our study provides actionable data to contain costs in the perioperative TSA setting. From the hospital's perspective, efforts to reduce implant purchase prices may translate into rapid substantial cost savings. At the patient level, multidisciplinary initiatives aimed at reducing length of stay and controlling medication expenses for patients at risk for high cost (e.g., infirm women with poor preoperative shoulder function) may prove effective in narrowing the existing patient-to-patient variation in costs. LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lateralized Center of Rotation and Lower Neck-Shaft Angle Are Associated With Lower Rates of Scapular Notching and Heterotopic Ossification and Improved Pain for Reverse Shoulder Arthroplasty at 1 Year.

Heterotopic ossification and scapular notching are common following reverse total shoulder arthroplasty. Compared with the original Grammont-style prosthesis with a medialized center of rotation (COR) and a 155° neck-shaft angle, lateralization of COR and reduction of neck-shaft angle have been associated with decreased incidence of scapular notching. The authors hypothesized that these design features may also be effective in reducing heterotopic ossification after reverse total shoulder arthroplasty. Ninety-seven consecutive patients who underwent reverse total shoulder arthroplasty performed by a single surgeon were included in the study. Forty-eight patients received a Grammont-style prosthesis, and 49 received a prosthesis with either 6 mm or 10 mm of lateral COR offset and a 135° neck-shaft angle. Radiographs at 1-year follow-up were reviewed by 2 surgeons for notching and heterotopic ossification. Patient-reported outcome scores and range of motion were also compared between the groups. More patients in the Grammont-style group showed scapular notching (Grammont, 35.4%; lateral COR, 12.2%; P=.018) and heterotopic ossification (Grammont, 47.9%; lateral COR, 22.4%; P=.009). The lateralized COR group reported lower pain on the visual analog scale (Grammont mean, 1.1; lateral COR mean, 0.5; P=.01) and trended toward better American Shoulder and Elbow Surgeons scores (Grammont mean, 77.2; lateral COR mean, 83.4; P=.05). However, range of motion was similar between the 2 groups. Compared with the Grammont-style prosthesis, the lateralized COR prosthesis with a decreased neck-shaft angle resulted in a lower incidence of both scapular notching and heterotopic ossification as well as better pain scores and a trend toward improved function at 1 year after reverse total shoulder arthroplasty. [Orthopedics. 2018; 41(4):230-236.].