Isolated Optic Neuritis: Etiology, Characteristics, and Outcomes in a US Mountain West Cohort.

BACKGROUND: The diagnosis and treatment of autoimmune optic neuritis (ON) has improved with the accessibility and reliability of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibody testing, yet autoantibody-negative ON remains common. This study describes the demographic, clinical, and outcome data in patients with isolated ON across the pediatric and adult cohort. METHODS: A retrospective chart review of University of Utah Health patients with the International Classification of Diseases (ICD) code of ICD-9 377.30 (ON unspecified), ICD-9 377.39 (other ON), or ICD-10 H46 (ON) and at least 2 ophthalmologic evaluations were conducted between February 2011 and July 2023. Only isolated cases of ON without other brain or spinal demyelinating lesions were evaluated. Differences in demographic and clinical characteristics between AQP4, MOG, and Other-ON were determined. RESULTS: Of the 98 patients (15 children and 83 adults), 9 (9.2%) were positive for AQP4-IgG and 35 (35.7%) tested positive for MOG-IgG. Fifty-four were classified into Other-ON, of which 7 (13.0%) had recurrence or new demyelinating lesions during a median follow-up of 12.5 months-2 were ultimately diagnosed with recurrent isolated ON (RION), 1 with chronic relapsing inflammatory ON (CRION), 2 with multiple sclerosis, 1 with collapsin response-mediator protein (CRMP)-5-ON, and 1 with seronegative neuromyelitis optica spectrum disorder. Four patients were treated with long-term immunosuppressive therapy. No patients with RION or CRION had preceding infections; they had first recurrences of ON within 2 months. At presentation, AQP4-ON (75%) and MOG-ON (48.8%) had more severe vision loss (visual acuity <20/200) than Other-ON (23.2%, P = 0.01). At the 1-month follow-up, 93.0% of patients with MOG-ON and 89.3% of patients with Other-ON demonstrated a visual acuity ≥20/40, compared with only 50% of patients with AQP4-ON (P < 0.01). By the last follow-up, 37.5% of the AQP4-ON still exhibited visual acuity <20/40, including 25% who experienced severe vision loss (visual acuity <20/200). By contrast, over 95% of patients with MOG-ON and Other-ON maintained a visual acuity of ≥20/40. In our cohort, over a quarter of pediatric cases presented with simultaneous bilateral ON, 40% had a preceding infection, and 44.4% initially presented with a visual acuity <20/200. Two pediatric cases had recurrence, and both were MOG-ON. By their last follow-up, all pediatric cases had achieved a visual acuity of 20/40 or better. In addition, pediatric cases were more likely to exhibit disc edema compared with adult cases (100% vs 64%, P < 0.01). CONCLUSIONS: Despite recent advances in identification and availability of testing for AQP4-IgG and MOG-IgG, over half of patients who presented with isolated ON remained with an "idiopathic" diagnostic label. As more than 1 in 10 patients with AQP4-IgG and MOG-IgG negative ON experienced recurrence or develop new demyelinating lesions, clinicians should provide anticipatory guidance and closely monitor for potential long-term outcomes. In addition, it is crucial to re-evaluate the diagnosis in cases of poor recovery, ON recurrence, and the emergence of new neurological symptoms, as ON can often be the initial presentation of other conditions.

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft.

BACKGROUND: Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. METHODS: This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. RESULTS: A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. CONCLUSION: In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Home health care is associated with an increased risk of readmission and cost of care without reducing risk of complication following shoulder arthroplasty: a propensity-score analysis.

BACKGROUND: Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services. METHODS: A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes. RESULTS: A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001). CONCLUSION: Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.

Funding bias in shoulder arthroplasty research.

BACKGROUND: Prior research has shown that industry funding can impact the outcomes reported in medical literature. Limited data exist on the degree of bias that industry funding may have on shoulder arthroplasty literature outside of the Journal of Shoulder and Elbow Surgery. The purpose of this study is to characterize the type and frequency of funding for recently published shoulder arthroplasty studies and the impact of industry funding on reported outcomes. We hypothesized that studies with industry funding are more likely to report positive outcomes than those without. MATERIALS AND METHODS: We performed a retrospective study searching all articles with the term "shoulder arthroplasty," "reverse shoulder arthroplasty," "anatomic total shoulder arthroplasty," or "total shoulder arthroplasty" on PubMed from the years January 2020 to December 2022. The primary outcome of studies was coded as either positive, negative, or neutral. A positive result was defined as one in which the null hypothesis was rejected. A negative result was defined as one in which the result did not favor the group in which the industry-funded implant was used. A neutral result was defined as one in which the null hypothesis was confirmed. Article funding type, subcategorized as National Institutes of Health funding or industry funding was recorded. Author disclosures were recorded to determine conflicts of interest. Statistical analysis was conducted using the χ2 test and Fisher exact test. RESULTS: A total of 750 articles reported on either conflict of interest or funding source and were included in the study. Of the total number of industry-funded studies, the majority were found to have a positive primary endpoint (58.1%, 104 of 179), as compared to a negative (7.8%, 14 of 179) or neutral endpoint (33.5%, 60 of 179) (P = .004). Overall, 363 articles reported an author conflict of interest, and the majority of these studies had positive primary endpoint (55.6%, 202 of 363) as compared to negative (9.1%, 33 of 363) or neutral endpoints (34.4%, 125 of 363) (P = .002). CONCLUSION: The results of this study suggest that there is a significant relationship between conflicts of interest and the primary outcome of shoulder arthroplasty studies, beyond the overall positive publication bias. Studies with industry funding and author conflicts of interest both report positive outcomes more frequently than negative outcomes. Shoulder surgeons should be aware of this potential bias when choosing to base clinical practice on published data.

Gender differences among shoulder arthroplasty surgeons: past, present, and future.

BACKGROUND: Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time. METHODS: The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members. RESULTS: The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P = .05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P < .001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P = .50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P < .001) and total hip arthroplasty (12.6% vs. 34.7%, P < .001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P = .017). DISCUSSION AND CONCLUSION: A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics-and to mentor female residents and medical students interested in shoulder surgery-may bring real change to the gender differences among shoulder replacement surgeons over the coming years.

Biomechanics of subscapularis V-shaped tenotomy compared to standard tenotomy.

BACKGROUND: Subscapularis function is critical after anatomic total shoulder arthroplasty (aTSA). Recently, however, a technique has been described that features a chevron or V-shaped subscapularis tendon cut (VT). This biomechanical study compared repair of the standard tenotomy (ST), made perpendicular to the subscapularis fibers, to repair of the novel VT using cyclic displacement, creep, construct stiffness, and load to failure. METHODS: This biomechanical study used 6 pairs of fresh frozen paired cadaveric shoulder specimens. One specimen per each pair underwent VT, the other ST. Subscapularis tenotomy was performed 1 cm from the insertion onto the lesser tuberosity. For VT, the apex of the V was 3 cm from the lesser tuberosity. After tenotomy, each humerus underwent humeral head arthroplasty. Eight figure-of-8 sutures were used to repair the tenotomy (Ethibond Excel; Ethicon, US LLC). Specimens were cyclically loaded from 2 to 100 N at 45 degrees abduction at a rate of 1 Hz for 3000 cycles. Cyclic displacement, creep, and stiffness and load to failure were measured. RESULTS: Cyclic displacement did not differ significantly between the ST and VT from 1 to 3000 cycles. The difference in displacement between the V-shaped and standard tenotomy at 3000 cycles was 1.57 mm (3.66 ± 1.55 mm vs. 5.1 ± 2.8 mm, P = .31, respectively). At no point was the V-shape tenotomy (VT) >3 mm of average displacement, whereas the standard tenotomy (ST) averaged 3 mm of displacement after 3 cycles. Creep was significantly lower for VT in cycles 1 through 3. For all cycles, stiffness was not significantly different in the VT group compared with the ST group. Load to failure was not statistically significant in the VT compared to the standard tenotomy throughout all cycles (253.2 ± 27.7 N vs. 213.3 ± 76.04 N; P = .25, respectively). The range of load to failure varied from 100 to 301 N for standard tenotomy compared with 216 to 308 N for VT. CONCLUSION: This study showed that VT and ST demonstrated equivalent stiffness, displacement, and load to failure. VT had the benefit of less creep throughout the first 3 cycles, although there was no difference from cycle 4 to 3000. The VT had equivalent biomechanical properties to the ST at time zero, an important first step in our understanding of the technique. The VT technique warrants further clinical study to determine if the technique has clinical benefits over ST following aTSA.

Cerebral blood flow and cerebrovascular reactivity are modified by maturational stage and exercise training status during youth.

NEW FINDINGS: What is the central question of this study? Gonadal hormones modulate cerebrovascular function while insulin-like growth factor 1 (IGF-1) facilitates exercise-mediated cerebral angiogenesis; puberty is a critical period of neurodevelopment alongside elevated gonadal hormone and IGF-1 activity: but whether exercise training across puberty enhances cerebrovascular function is unkown. What is the main finding and its importance? Cerebral blood flow is elevated in endurance trained adolescent males when compared to untrained counterparts. However, cerebrovascular reactivity to hypercapnia is faster in trained vs. untrained children, but not adolescents. Exercise-induced improvements in cerebrovascular function are attainable as early as the first decade of life. ABSTRACT: Global cerebral blood flow (gCBF) and cerebrovascular reactivity to hypercapnia ( CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ) are modulated by gonadal hormone activity, while insulin-like growth factor 1 facilitates exercise-mediated cerebral angiogenesis in adults. Whether critical periods of heightened hormonal and neural development during puberty represent an opportunity to further enhance gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ is currently unknown. Therefore, we used duplex ultrasound to assess gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ in n = 128 adolescents characterised as endurance-exercise trained (males: n = 30, females: n = 36) or untrained (males: n = 29, females: n = 33). Participants were further categorised as pre- (males: n = 35, females: n = 33) or post- (males: n = 24, females: n = 36) peak height velocity (PHV) to determine pubertal or 'maturity' status. Three-factor ANOVA was used to identify main and interaction effects of maturity status, biological sex and training status on gCBF and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ . Data are reported as group means (SD). Pre-PHV youth demonstrated elevated gCBF and slower CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response times than post-PHV counterparts (both: P ≤ 0.001). gCBF was only elevated in post-PHV trained males when compared to untrained counterparts (634 (43) vs. 578 (46) ml min-1 ; P = 0.007). However, CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response time was faster in pre- (72 (20) vs. 95 (29) s; P ≤ 0.001), but not post-PHV (P = 0.721) trained youth when compared to untrained counterparts. Cardiorespiratory fitness was associated with gCBF in post-PHV youth (r2  = 0.19; P ≤ 0.001) and CV R C O 2 ${\mathrm{CV}}{{\mathrm{R}}_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ mean response time in pre-PHV youth (r2  = 0.13; P = 0.014). Higher cardiorespiratory fitness during adolescence can elevate gCBF while exercise training during childhood primes the development of cerebrovascular function, highlighting the importance of exercise training during the early stages of life in shaping the cerebrovascular phenotype.

Payor type is associated with increased rates of reoperation and health care utilization after rotator cuff repair: a national database study.

BACKGROUND: Despite strong evidence supporting the efficacy of rotator cuff repair (RCR), previous literature has demonstrated that socioeconomic disparities exist among patients who undergo surgery. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation after RCR. METHODS: Patients with Medicare, Medicaid, or commercial payor-type insurance who underwent primary open or arthroscopic RCR between 2010 and 2019 were identified using a large national database. Ninety-day incidence of medical complications, emergency department (ED) visit, and hospital readmission, as well as 1-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated. Propensity-score matching was used to control for patient demographic factors and comorbidities as covariates. RESULTS: A total of 113,257 Medicare, 23,074 Medicaid, and 414,447 commercially insured patients were included for analysis. Medicaid insurance was associated with an increased 90-day risk of various medical complications, ED visit (odds ratio [OR]: 2.87; P < .001), and 1-year revision RCR (OR: 1.60; P < .001) compared with Medicare insurance. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit (OR: 2.98; P < .001), and hospital readmission (OR: 1.56; P = .002), as well as 1-year risk of revision RCR (OR: 1.60; P < .001) and conversion to arthroplasty (OR: 1.4358; P < .001) compared with commercially insured patients. Medicaid insurance was associated with a decreased risk of conversion to arthroplasty compared with Medicare patients (OR: 0.6887; P < .001). Medicaid insurance was associated with higher 1-year cost of care compared with patients with both Medicare (P < .001) and commercial insurance (P < .001). DISCUSSION: Medicaid insurance is associated with increased rates of medical complications, health care utilization, and reoperation after rotator cuff surgery, despite controlling for covariates. Medicaid insurance is also associated with a higher 1-year cost of care. Understanding the complex relationship between sociodemographic factors, such as insurance status, medical comorbidities, and outcomes, is necessary to ensure optimal health care access for all patients and to allow for appropriate risk stratification.

Effect of reverse shoulder arthroplasty humeral component retroversion on acromial strain.

INTRODUCTION: Acromion and scapular spine stress fractures can be catastrophic complications following reverse shoulder arthroplasty (RSA). A variety of host, implant, and technical factors have been identified that increase the risk of this complication. The glenoid component in particular has been closely evaluated for its impact on rates of stress fractures following RSA. The goal of this biomechanical study is to evaluate if humeral stem version has an impact on acromion and scapular spine strain after RSA. METHODS: Eight cadaveric specimens were tested on a custom dynamic shoulder frame. Commercially available RSA components were implanted with the humeral component inserted in 0° of retroversion. Acromion and scapular spine strain were measured at 0°, 30°, and 60° of abduction using strain rosettes secured to the acromion and scapular spine in the typical locations for Levy type II and type III stress fractures, respectively. The humeral stem was then removed and reimplanted in 30° of retroversion and the measurements were repeated. Student t test was performed to analyze the relationship between humeral stem version and acromion and scapular spine strain at various abduction angles. RESULTS: Strain at the both the acromion and scapular spine were found to have no significant difference at any abduction angle when comparing 0° and 30° version of the humeral stem. With 0° and 30° versions pooled together, there is significantly lower acromion and scapular spine strain at 60° of abduction when compared to 0° of abduction (strain at 0° abduction - strain at 60° abduction: acromion 313.1 µêœª; P = .0409, Scapular spine 304.9 µêœª; P = .0407). There was no significant difference in strain at either location when comparing 0° of abduction to 30° of abduction and when comparing 30° of abduction to 60° of abduction. CONCLUSIONS: This biomechanical study found no significant difference in scapular spine and acromion strain after RSA when comparing variations in humeral stem version. There does appear to be lower strain at both the acromion and scapular spine at 60° of abduction when compared to 0° of abduction regardless of stem version.

Impact of radiocapitellar interposition arthroplasty on ulnohumeral joint biomechanics.

BACKGROUND: Radial head excision (RHE) has been shown to increase contact pressures within the ulnohumeral joint. Radiocapitellar interposition arthroplasty (RCIA) with the use of a soft tissue graft is an alternative for the treatment of isolated radiocapitellar arthritis or with failure of radial head replacement. We investigated contact pressures and contact area within the ulnohumeral joint after RHE compared to RCIA with dermal autograft. METHODS: Six fresh-frozen cadaver elbows were tested on a custom dynamic elbow frame. A pressure sensor was inserted into the intact elbow joint, and mean contact pressure, peak contact pressure, contact area, and force within the ulnohumeral joint were recorded at 0°, 30°, 60°, 90°, and 120° of flexion as a valgus load was applied to the elbow. The radial head was then excised and specimens were retested. Finally, a dermal graft matched to the size of the resected radial head was inserted in the radiocapitellar space and the specimens were tested a third time. RESULTS: At 90° of flexion, contact pressure within the ulnohumeral joint was significantly lower with RCIA compared with RHE (110.8 kPa vs 216.8 kPa; P = .013). The mean peak contact pressure was also significantly lower with RCIA compared with RHE at 90° (279.4 vs 626.7 kPa; P = .025). No statistically significant differences were seen in mean contact area or force between the 3 testing conditions at any flexion position. CONCLUSION: RCIA with a dermal graft reduced contact pressures within the ulnohumeral joint compared to RHE at 90° of flexion without a significant change in contact area or contact force.

Predicting successful outpatient total shoulder arthroplasty.

BACKGROUND: Total shoulder arthroplasty (TSA) is increasingly performed safely and efficiently as an outpatient procedure in certain patients. Patient selection is often based on surgeon choice, surgeon expertise, or institutional guidelines. One orthopedic research group released a publicly available shoulder arthroplasty outpatient appropriateness risk calculator that considers patient demographic characteristics and comorbidities with the aim of helping surgeons to predict successful outpatient TSA. This study aimed to retrospectively assess the utility of this risk calculator at our institution. METHODS: Records were obtained for patients undergoing procedure code 23472 at our institution between January 1, 2018, and March 31, 2021. Patients undergoing anatomic TSA in the hospital setting were included. Records were reviewed for demographic characteristics, comorbidities, American Society of Anesthesiologists classification, and surgery duration. These data were entered into the risk calculator to calculate the likelihood of discharge by postoperative day 1. Charlson Comorbidity Index, complications, reoperations, and readmissions were also collected from patient records. Statistical analyses assessed the model's fit with our patient cohort and compared outcome measures between inpatient and outpatient groups. RESULTS: Of the 792 patients whose records were initially obtained, 289 met the inclusion criteria of anatomic TSA performed in the hospital setting. Of these patients, 7 were excluded because of missing data, leaving 282 patients: 166 (58.9%) in the inpatient group and 116 (41.1%) in the outpatient group. We found no significant differences in mean age (66.4 years in inpatient group vs. 65.1 years in outpatient group, P = .28), Charlson Comorbidity Index (3.48 vs. 3.06, P = .080), or American Society of Anesthesiologists class (2.58 vs. 2.66, P = .19). Surgery time was longer in the inpatient group than the outpatient group (85 minutes vs. 77 minutes, P = .001). Overall complication rates were low (4.2% in inpatient group vs. 2.6% in outpatient group, P = .07). Readmissions and reoperations did not differ between groups. There was no difference in the average percentage likelihood of same-day discharge (55.4% in inpatient group vs. 52.4% in outpatient group, P = .24), and a receiver operating characteristic curve to assess fit with the risk calculator demonstrated an area under the curve of 0.55. DISCUSSION: The shoulder arthroplasty risk calculator performed similarly to chance when retrospectively predicting discharge within 1 day after TSA in our patients. Complications, readmissions, and reoperations were not higher after outpatient procedures. Risk calculators for determining whether a patient should be admitted after TSA should be used cautiously because they may not provide measurable benefit over the use of surgeon experience and expertise in discharge decision making, and other factors may be relevant in the decision to perform outpatient TSA.

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis.

BACKGROUND: Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. METHODS: A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated. RESULTS: Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. CONCLUSIONS: This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Fragility of randomized controlled trials on treatment of proximal humeral fracture.

BACKGROUND: Proximal humeral fracture represents an increasingly common pathology with evaluation and treatment often guided by evidence from randomized controlled trials (RCTs), but the strength of an RCT must be considered in this process. The purpose of this study was to evaluate the strength of outcomes in RCTs on the management of proximal humeral fractures using the fragility index (FI), a method used with statistically significant dichotomous outcomes to assess the number of patients that would change an outcome measure from significant (P ≤ .05) to nonsignificant if the patient outcome changed. We also aimed to correlate the FI with other measures of study strength. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to evaluate RCTs on the management of proximal humeral fractures. The PubMed, Ovid MEDLINE, Web of Science, and Embase databases were searched from database inception to May 2021. RCTs with at least 1 statistically significant (P ≤ .05) dichotomous outcome were included. The FI was calculated for each included trial using the Fisher exact test. The FI was correlated with the study sample size and journal impact factor. RESULTS: Ten RCTs reporting on 656 patients and published between 2011 and 2020 were included. The median patient sample size was 67 (mean, 65.6; range, 40-86). Complications were the most commonly reported dichotomous statistically significant outcome. The median FI was 1 (mean, 2.6; range, 0-18), with 4 studies having an FI of 0. A median FI of 1 indicates that 1 patient experiencing an alternative outcome or having not been lost to follow-up could have changed the pertinent conclusions of the trial for a given outcome. The median number of patients lost to follow-up was 3 (mean, 4.9; range, 0-16) and exceeded the FI in 50% of studies. There was no correlation between the FI and sample size (Spearman coefficient = 0.0592, P = .865) or between the FI and journal impact factor (Spearman coefficient = -0.0229, P = .522). CONCLUSION: In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied. Although the FI cannot be used to assess continuous variables, which are often the primary outcome variables of RCTs, it does offer an additional unique measure of study strength that surgeons should consider when evaluating RCTs.

Evaluation of clinical and radiographic outcomes after total shoulder arthroplasty with inset Trabecular Metal-backed glenoid.

BACKGROUND: Trabecular Metal (TM)-backed glenoid implants were introduced for their theoretical ability to increase osseointegration while minimizing wear and the risk of loosening in total shoulder arthroplasty (TSA). Initial follow-up studies of TM-backed glenoids demonstrated high rates of metallic debris formation around the implant site, raising concerns about longevity. More recent data suggest that metallic debris formation may be less prevalent than previously reported and that the implants may have positive long-term outcomes regardless of debris. The goal of our study was to assess the clinical and radiographic outcomes at mid-term follow-up of TSA using a TM-backed glenoid implant placed with full backside support using an inset technique. We hypothesized that our clinical and radiographic outcomes would be good using this technique. METHODS: We retrospectively reviewed the charts of 39 patients who underwent 41 TSA procedures with a Zimmer Biomet TM-backed glenoid component performed by a single surgeon between January 2010 and March 2016. After exclusions for death unrelated to surgery and loss to follow-up, 35 patients (37 shoulders) with minimum 2-year clinical follow-up were included in the study. The glenoids were all placed in an inset fashion with full backside support. Clinical, patient-reported, and radiographic outcomes were analyzed. RESULTS: The average follow-up period was 7.2 years (range, 2-11 years). At final follow-up, average shoulder elevation was 153° ± 22° and average external rotation was 53° ± 12°. The average American Shoulder and Elbow Surgeons score was 86.8 ± 19.0, and the average visual analog scale score was 1.3 ± 2.4. Metallic debris was found in 9 shoulders (27%), and radiolucency was observed around the glenoid components in 13 shoulders (39%) on the final postoperative radiographs. Metallic debris and radiolucency findings were low in severity, with average grades of 0.32 (standard deviation, 0.54) and 0.39 (standard deviation, 0.50), respectively. There were no reoperations. CONCLUSION: This study of 37 shoulders undergoing TSA with a TM-backed glenoid demonstrated 100% implant survivorship at an average follow-up of 7 years. Clinical outcomes were excellent despite the occurrence of some metallic debris formation. The findings suggest that a TM-backed glenoid component implanted in an inset fashion to achieve full backside support can provide good clinical and patient-reported outcomes in TSA patients at mid-term follow-up and suggest that continued consideration of the role of TM-backed glenoids and the optimal technique for implantation may be warranted.

The relationship between academic influence, NIH funding, and industry payments among academic shoulder and elbow surgeons.

BACKGROUND: The effect of academic influence, or the volume and quality of a surgeon's publications, on industry payments and National Institutes of Health (NIH) funding has recently been studied in some academic orthopedic subspecialities. The purpose of this study is to evaluate the relationship between academic influence, industry payments, and NIH funding among American Shoulder and Elbow Surgeons accredited shoulder and elbow fellowship faculty. METHODS: Shoulder and elbow fellowships and affiliated faculty members were identified from the American Shoulder and Elbow Surgeons website. Academic influence, measured by the Hirsch (h)-index, and the number of articles published were determined for faculty members using the Scopus Database Author Identifier tool. Industry payments were derived from the Centers for Medicare and Medicaid Services Open Payments database. NIH funding was determined using the NIH's Research Portfolio Online Reporting tool. Statistical analysis used Spearman correlations and the Mann-Whitney U-test with an alpha value of 0.05 (P < .05). RESULTS: A total of 146 faculty members were included. Twenty-two percent (42 of 146) received nonresearch payments, whereas 78% (114 of 146) received industry research funding averaging $6364 (standard deviation = $21,213). NIH funding averaged $272,589 (standard deviation = $224,635), and 5% received NIH funding (7 of 146). Faculty members who received NIH funding had a higher average h-index than those who did not (38 ± 22 vs. 22.64 ± 22.7, P = .02), whereas those receiving industry research payments had a greater number of publications than those who did not (127.97 ± 127.2 vs. 100.3 ± 122.3, P = .03). Industry nonresearch payments did not impact the number of publications or the h-index. DISCUSSION/CONCLUSION: This study demonstrated that academic influence among academic shoulder and elbow surgeons is not greater in those who receive nonresearch industry funding. However, surgeons with industry research funding did produce more publications, whereas NIH funding is associated with greater academic influence.

Gender disparities in shoulder and elbow publications.

HYPOTHESIS/BACKGROUND: Female representation in orthopedics, and specifically shoulder and elbow surgery, lags behind other surgical subspecialities. There has been a growing interest in recent years to better characterize, and address, gender disparities in the field. The purpose of this investigation was to characterize gender trends in authorship in the shoulder and elbow literature from 2002 to 2020. METHODS: Articles published from January 2002 to December 2020 in 15 clinical orthopedic and shoulder- and elbow-specific journals were extracted from the online PubMed database. Articles that included the first name of the first and senior authors and contained keywords related to the shoulder and elbow subspecialty were included. The Genderize algorithm was used to determine each author's gender. Gender-based publication trends from 2002 to 2020 were analyzed using descriptive and significance testing as well as logistic regression. RESULTS: 34,695 articles met inclusion criteria and 52,497 unique authors were identified. Of these unique authors, 10,175 (19.4%) were female and 42,322 (80.6%) were male. On average, each unique female author published 1.7 ± 0.1 manuscripts since 2002 and each male author published 2.5 ± 0.2 (P < .001). Female representation in shoulder and elbow publications began at 10.2% in 2002 and rose to 15.9% in 2020 (P < .001). Female representation in the lead author position began at 4.1% in 2002 and rose to 5.8% in 2020 (P = .009). Female representation in the senior author position began at 6.0% in 2002 and rose to 9.1% in 2020 (P < .001). CONCLUSION: Although female representation in first, senior, and general authorship lags behind male representation in the shoulder and elbow literature, female authorship has significantly increased since 2002. The same men tend to publish more frequently while the number of unique female authors surpasses the annual representation of female authorship. Efforts to improve female representation in the field of orthopedic surgery should include efforts directed at improving female representation in academic literature.

An investigation into gender bias in the evaluation of orthopedic trainee arthroscopic skills.

BACKGROUND: Women surgeons receive lower compensation, hold fewer academic positions, and hold fewer leadership positions than men, particularly in orthopedic surgery. Gender bias at the trainee level has been demonstrated in various surgical subspecialties, but there is a lack of information on gender bias within the orthopedic training environment. This study investigated whether implicit gender bias is present in the subjective evaluation of orthopedic trainee arthroscopic skills. METHODS: After institutional review board approval, a web-based survey was sent to American Shoulder and Elbow Surgeons (ASES) members via the society's email listserve. Study participants were informed that the study was being done to develop a systematic evaluation method for trainees. The survey randomized participants to view and evaluate a prefellowship and a postfellowship video of "Rachel" (she/her) or "Charles" (he/him) performing a 15-point diagnostic shoulder arthroscopy. The videos for Rachel and Charles were identical except for the pronouns used in the video. Participants evaluated the trainee's skill level using questions from the Arthroscopic Surgical Skill Evaluation Tool (ASSET). Blinded and deidentified additional comments regarding the trainee's skill were classified as positive, negative, or neutral. Statistical analyses were used to compare scores and comments between Rachel and Charles. RESULTS: Of 1115 active ASES members, 181 ASES members started the survey and 106 watched both videos and were included in the analysis. Of the 106 participants completing the survey, 96 (91%) were men and 10 (9%) were women with a median (interquartile range) age of 44 (38-51). A teaching role was reported by 84 of 106 participants (79%). There was no significant difference between prefellowship scores (P = .87) or between postfellowship scores (P = .84) for the woman and man fellow. The numbers of comments classified as positive, negative, or neutral were not significantly different between the man and woman fellow (P = .19). Participants in teaching roles gave significantly lower scores to both fellows at both time points (P = .04), and participants who had fellow trainees were more likely to give negative comments to both fellows (P = .02). DISCUSSION: Trainee gender did not influence the ratings and comments participants gave for trainee arthroscopic skills, suggesting that gender bias may not play a major role in the evaluation of arthroscopic skill during orthopedic training.

Monitoring changes in human activity during the COVID-19 shutdown in Las Vegas using infrasound microbarometers.

While studies of urban acoustics are typically restricted to the audio range, anthropogenic activity also generates infrasound (<20 Hz, roughly at the lower end of the range of human hearing). Shutdowns related to the COVID-19 pandemic unintentionally created ideal conditions for the study of urban infrasound and low frequency audio (20-500 Hz), as closures reduced human-generated ambient noise, while natural signals remained relatively unaffected. An array of infrasound sensors deployed in Las Vegas, NV, provides data for a case study in monitoring human activity during the pandemic through urban acoustics. The array records a sharp decline in acoustic power following the temporary shutdown of businesses deemed nonessential by the state of Nevada. This decline varies spatially across the array, with stations close to McCarran International Airport generally recording the greatest declines in acoustic power. Further, declines in acoustic power fluctuate with the time of day. As only signals associated with anthropogenic activity are expected to decline, this gives a rough indication of periodicities in urban acoustics throughout Las Vegas. The results of this study reflect the city's response to the pandemic and suggest spatiotemporal trends in acoustics outside of shutdowns.

Case report: Increasing the frequency of intramuscular naltrexone administration in a high risk patient with opioid use disorder.

Background: As the United States faces a national opioid crisis, opioid overdose deaths have significantly risen over the past decade. Patients with opioid use disorder, particularly those who use high-potency synthetic opioids, are at an increased risk of fatal opioid overdose. Alternative dosing strategies for the treatment of opioid use disorder must be considered in high-risk patients to prevent opioid overdose. Case: One patient with opioid use disorder at high risk for overdose was treated with extended-release (XR) intramuscular (IM) naltrexone initially every 28 days, but was frequently reporting increased cravings during the week prior to the next injection being due. This patient's dose of XR IM naltrexone was then given at an increased dosing frequency of every 21-24 days for three months. Opioid craving suppression was achieved without clinical or laboratory evidence of side effects or hepatotoxicity. Discussion: In patients with especially high risk of opioid overdose, consideration of novel dosing strategies for continuation of opioid abstinence is necessary. This is the first report demonstrating the short-term safety and efficacy of more frequent dosing of XR IM naltrexone. This case demonstrates that in select high-risk patients, more frequent dosing of XR IM naltrexone may be an effective strategy to reduce opioid cravings. Informed Consent: The case was reviewed with the Intuition's Privacy Officer who informed the authors that informed consent could not be obtained by the patient's family members due to 38 U.S.C 7332 restrictions on protected information. This manuscript was de-identified and approved by the institution's local privacy officer for publication in accordance with institution policy.

Social Deprivation and Congenital Upper Extremity Differences-An Assessment Using PROMIS.

PURPOSE: Social deprivation, a measure of socioeconomic status, has been shown to negatively affect perceptions of orthopedic conditions and outcomes of treatment. The objective of this study was to assess whether social deprivation correlates with subjective assessment of function in pediatric patients with congenital hand differences. METHODS: Patients enrolled in the Congenital Upper Limb Differences (CoULD) registry were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). The PROMIS scores for Pain Interference, Peer Relations, Anxiety, Depression, and Upper Extremity (UE) function were obtained for all patients 5 years and older at initial presentation. Social deprivation was determined by the Area Deprivation Index (ADI); the index ranges from 0 to 100 with higher scores being the most deprived. The PROMIS scores were correlated with the ADI for all patients. RESULTS: Three hundred seventy-five pediatric patients with congenital UE differences were evaluated. Average age was 11 years, 56% were female, and 55% had bilateral involvement. Overall, PROMIS scores were within 1 SD of normal for Peer Relations, Pain, Depression, and Anxiety. However, child-reported scores for UE function (39) were more than 1 SD below the national average (50). The mean ADI for the cohort was lower than the national average, indicative of less deprivation, with 14% of patients in the most deprived national quartile. Children in the highest ADI quartile reported PROMIS scores that reflected higher Pain Interference (41 vs 45), lower Peer Relations (55 vs 50), higher Anxiety (44 vs 49), and higher Depression (43 vs 47) than children in the lowest ADI quartile. CONCLUSIONS: The PROMIS scores were normal for psychosocial measures in children with congenital hand differences when evaluated as an entire cohort. However, child self-reported PROMIS scores for Pain Interference, Peer Relations, Anxiety, and Depression were worse in more socially deprived areas, suggesting more psychosocial challenges in these children. CLINICAL RELEVANCE: Pediatric patients with congenital upper extremity differences in areas of higher social deprivation report lower psychosocial well-being. The care of these individuals must be considered within the context of their environment because they may be more at risk for negative outcomes secondary to environmental and societal stressors.