Optimal combination of arthroplasty type, fixation method and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: A network meta-analysis.

PURPOSE: The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature. METHODS: A systematic review of the literature using PRISMA guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007-2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R. RESULTS: A total of 28 studies (1,119 patients) were included with an average age of 74±3.7 and mean follow-up of 32±11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4±0.76 weeks compared to 5.9±1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126±27.5), abduction (116±30.6), internal rotation (5.27±0.74, corresponding to L3-L1), ASES score (71.8±17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 years old with acute PHF undergoing shoulder arthroplasty (all p≤0.05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (p=0.005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (OR, 0.30; p=0.01 & OR, 0.42; p=0.05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) versus (8.91%) in the press fit rTSA subgroups (p=0.02). CONCLUSION: Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of range of motion, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative range of motion when compared to the mainstream preference-rTSA-Cement-Delayed.

Management of Humeral Shaft Fracture: A Network Metanalysis of Individual Treatment Modalities.

OBJECTIVE: The purpose of this study was to perform a network meta-analysis (NMA) of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSF). METHODS: Data Sources: A systematic review of the literature using PRISMA guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2010-2023. STUDY SELECTION: Inclusion criteria were evidence level I or II studies comparing nonoperative and/or operative repair techniques including open reduction internal fixation plate osteosynthesis (ORIF-Plate), minimally invasive percutaneous plating (MIPO), and intramedullary nail fixation (IMN) for the management of HSF (AO OTA 12A,B,C). DATA EXTRACTION: The risk of bias (ROB) and methodologic quality of evidence (MQOE) were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group. DATA SYNTHESIS: NMA were conducted with a frequentist approach with a random effects model using the netmeta package version 0.9-6 in R. RESULTS: A total of 25 studies (1,908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared to ORIF-Plate (16.1%) (OR, 0.13;95%CI,0.04-0.49). MIPO resulted in the lowest nonunion rate (0.65%) compared to all management techniques (OR 0.28; 95%CI, 0.08-0.98), whereas Non-Op resulted in the highest (15.87%) (OR,3.48; 95%CI, 1.98-6.11). MIPO demonstrated the lowest rate of postoperative radial nerve palsy overall (2.2%) and demonstrated a significantly lower rate compared to ORIF-Plate (OR,0.22,95% CI, 0.07-0.71, p=0.02). IMN resulted in the lowest rate of deep infection (1.1%) when compared to ORIF-Plate (8.6%; p=0.013). MIPO resulted in a significantly lower DASH score (3.86±5.2) and higher ASES score (98.2± 1.4) than ORIF-Plate (19.5±9.0 & 60.0±5.4, p<0.05). CONCLUSION: The results from this study support that surgical management results in better postoperative functional outcomes, leads to higher union rates, reduces fracture healing time, reduces revision rate and decreases malunion rates in patients with HSFs. Additionally, MIPO resulted in statistically higher union rates, lowest complication rate, lowest rate of postoperative radial nerve palsy, and lower intraoperative time, while resulting in better postoperative DASH and ASES scores when compared to nonoperative and operative (ORIF & IMN) treatment modalities. LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty outcomes in Ehlers-Danlos patients: data from the Statewide Planning and Research Cooperative System.

INTRODUCTION: Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after primary total hip arthroplasty (THA) in this patient population remain poorly characterised. The primary purpose of this study is to compare postoperative outcomes and survivorship after primary THA in patients with and without EDS. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for all patients undergoing primary elective THA between September 2009 and December 2020. Patients with EDS were identified using ICD9 and ICD10 diagnosis codes. Given the relatively low incidence of EDS in this patient population, the cohort was propensity-matched 1:10 to patients without diagnosis of EDS based on demographics characteristics and medical comorbidities as measured by the Elixhauser Comorbidity Index. RESULTS: A total of 66 THA patients with and 660 without EDS were included in each group after 1:10 propensity-matching. There were no significant differences in baseline characteristics or THA indications. Early postoperative outcomes such as length of hospital stay and discharge disposition were similar. Emergency Room visits and inpatient readmission rates at 3 months postoperatively did not significantly differ between groups. Patients with EDS had a higher overall revision rate compared to those without (15.0% vs. 3.2%, p < 0.001). Revision free survival after primary THA in patients with EDS was significantly lower than those without EDS at 9-year follow-up. Cox proportional hazard regression demonstrated EDS patients had 7-times higher risk of revision (hazard ratio [HR] 7.43; 95% CI, 3.46-16.00; p < 0.001). Lastly, revision due to instability insignificantly trended higher in the EDS cohort (HR 2.29; 95% CI, 0.95-5.49; p = 0.063). CONCLUSIONS: EDS patients undergoing primary THA have increased rate of all cause revision and demonstrate decreased revision free survival compared to non-EDS THA patients.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

Tranexamic acid reduces perioperative blood loss and postoperative hemoglobin loss during total ankle arthroplasty: A systematic review and meta-analysis of clinical comparative studies.

IMPORTANCE: Peri-operative blood loss during joint replacement procedures is a modifiable risk factor that impacts wound complications, hospital stay and total costs. Tranexamic acid (TXA) is an anti-fibrinolytic that has been widely used in orthopedic surgery, but its efficacy in the setting of total ankle arthroplasty (TAA) has not been quantified to date. AIM: The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of administering TXA in patients undergoing TAA. EVIDENCE REVIEW: The Medline, Embase and Cochrane library databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five comparative studies examining blood loss following administration of TXA for patients undergoing TAA were included. The outcome measures of interest were blood loss, reduction in hemoglobin concentration, transfusion requirements, total complications and wound complications. FINDINGS: In total, 194 patients received TXA and 187 patients did not receive TXA while undergoing TAA. Based on the common-effects model for total blood loss for the TXA group versus control, the standardized mean difference (SMD) was -0.7832 (95% CI, -1.1544, -0.4120; P â€‹< â€‹0.0001), in favor of lower total blood loss for TXA. Based on the random-effects model for reduction in hemoglobin for the TXA group versus control, the SMD was -0.9548 (95% CI, -1.7850, -0.1246; P â€‹= â€‹0.0242) in favor of lower hemoglobin loss for TXA. Based on the random-effects model for total complications for the TXA group versus control, the risk ratio was 0.512 (95% CI, 0.1588, 1.6512; P â€‹= â€‹0.1876), in favor of lower total complications for TXA but this was not statistically significant. CONCLUSIONS: This current review demonstrated that administration of TXA led to a reduction in blood loss and hemoglobin loss without an increased risk of the development of venous thromboembolism in patients undergoing TAA. No difference was observed with respect to total complication rates between the TXA cohort and the control group. TXA appears to be an effective hemostatic agent in the setting of TAA, but further studies are necessary to identify the optimal timing, dosage and route of TXA during TAA. LEVEL OF EVIDENCE: III.

The significance of heterotopic ossification following total ankle arthroplasty: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to evaluate the prevalence and clinical significance of heterotopic ossification (HO) following total ankle replacement (TAR). METHODS: During August 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies reporting HO following TAR. Data regarding surgical characteristics, pathological characteristics, subjective clinical outcomes, ankle range of motion, radiographic outcomes, reoperation rates were extracted and analysed. RESULTS: Twenty-seven studies with 2639 patients (2695 ankles) at a weighed mean follow-up time of 52.8 ± 26.9 months were included. The pooled prevalence rate was 44.6% (0.25; 0.66). The implant with the highest rate of HO was the INBONE I (100%) and BOX (100%) implants. The most common modified Brooker staging was grade 1 (132 patients, 27.0%). Random effects models of standardized mean differences found no difference in American orthopedic foot and ankle society (AOFAS) scores, visual analog scale scores (VAS) and ankle range of motion (ROM) between patients with HO and patients without HO. Random effects models of correlation coefficients found no correlation between AOFAS, VAS and ROM and the presence of HO. The surgical intervention rate for symptomatic HO was 4.2%. CONCLUSION: This systematic review and meta-analysis found that HO is a common finding following TAR that is not associated with inferior clinical outcomes. Surgical intervention was required only for moderate-to-severe, symptomatic HO following TAR. This study is limited by the marked heterogeneity and low level and quality of evidence of the included studies. Further higher quality studies are warranted to determine the precise prevalence and impact of HO on outcomes following TAR.

Do Patients With Insulin-Dependent and Non-Insulin-Dependent Diabetes Have Different Risks for Complications After Total Ankle Arthroplasty?

BACKGROUND: Patients with diabetes undergoing total ankle arthroplasty tend to be at greater risk for complications than those without diabetes. However, the effect of diabetes severity and how it impacts the risk for perioperative complications is less clear. The purpose of this study was to compare (1) complications, (2) length of hospital stay, and (3) readmissions within 30 days for total ankle arthroplasty (TAA) patients without diabetes, patients with non-insulin-dependent diabetes, and patients with insulin-dependent diabetes. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a total of 1803 patients undergoing TAA between 2007 and 2019 were collected. The relationship between diabetes status (no diabetes [n = 1,589], insulin-dependent [n = 169], and non-insulin-dependent [n = 45]) and outcomes were compared. Multivariate linear regression models were used to adjust for confounding variables such as age, sex, race, body mass index, smoking, steroid use, hypertension, chronic obstructive pulmonary disease, anesthesia type, dyspnea, and outpatient status. Statistical significance was set at P <.05. RESULTS: Insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days (odds ratio 6.47, 95% CI 0.79-33.66; P = .043). Hospital length of stay was also increased in patients with non-insulin-dependent diabetes (ß = 0.21, 95% CI 0.02-0.40; P = .031) and insulin-dependent diabetes (ß = 0.40, 95% CI 0.04-0.76; P = .028). However, neither diabetic state demonstrated a statistically significant increase in readmissions or wound complications within 30 days. CONCLUSION: Patients with insulin-dependent diabetes included in this cohort were at increased risk of having an infection within 30 days after TAA. Additionally, patients with diabetes status had an increased hospital length of stay. These results can inform patients on their potential outcomes after total ankle arthroplasty based on their diabetes status. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Role of Hyaluronan/Receptor for Hyaluronan-Mediated Motility Interactions in the Modulation of Macrophage Polarization and Cartilage Repair.

Hyaluronan (HA), a negatively charged linear glycosaminoglycan, is a key macromolecular component of the articular cartilage extracellular matrix. The differential effects of HA are determined by a spatially/temporally regulated display of HA receptors, such as CD44 and receptor for hyaluronan-mediated motility (RHAMM). HA signaling through CD44 with RHAMM has been shown to stimulate inflammation and fibrotic processes. This study shows an increased expression of RHAMM in proinflammatory macrophages. Interfering with HA/RHAMM interactions using a 15-mer RHAMM-mimetic, HA-binding peptide, together with high-molecular-weight (HMW) HA reduced the expression and release of inflammatory markers and increased the expression of anti-inflammatory markers in proinflammatory macrophages. HA/RHAMM interactions were interfered in vivo during the regeneration of a full-thickness cartilage defect after microfracture surgery in rabbits using three intra-articular injections of 15-mer RHAMM-mimetic. HA-binding peptide together with HMWHA reduced the number of proinflammatory macrophages and increased the number of anti-inflammatory macrophages in the injured knee joint and greatly improved the repair of the cartilage defect compared with intra-articular injections of HMWHA alone. These findings suggest that HA/RHAMM interactions play a key role in cartilage repair/regeneration via stimulating inflammatory and fibrotic events, including increasing the ratio of proinflammatory/anti-inflammatory macrophages. Interfering with these interactions reduced inflammation and greatly improved cartilage repair.

The Role of Amino Acid Supplementation in Orthopaedic Surgery.

The nutritional status of patients undergoing orthopaedic surgery has started to garner increasing attention in published literature. Notable previous evidence has demonstrated the negative effect of malnutrition on outcomes after orthopaedic procedures. Although there has been increased recognition of malnutrition as a risk factor for suboptimal outcomes, the use of nutritional supplementation to mitigate those risks is not well understood. The purpose of this review of most current literature on the topic is to introduce and elucidate the role of amino acid supplementation as a countermeasure to muscle loss and improvement of nutritional status in orthopaedic patients to improve results and outcomes after orthopaedic surgery.

Positive outcome reporting in orthopaedic literature.

Aims: Perthes' disease (PD) is a relatively rare syndrome of idiopathic osteonecrosis of the proximal femoral epiphysis. Treatment for Perthes' disease is controversial due to the many options available, with no clear superiority of one treatment over another. Despite having few evidence-based approaches, many patients with Perthes' disease are managed surgically. Positive outcome reporting, defined as reporting a study variable producing statistically significant positive (beneficial) results, is a phenomenon that can be considered a proxy for the strength of science. This study aims to conduct a systematic literature review with the hypothesis that positive outcome reporting is frequent in studies on the treatment of Perthes' disease. Methods: We conducted a systematic review of all available abstracts associated with manuscripts in English or with English translation between January 2000 and December 2021, dealing with the treatment of Perthes' disease. Data collection included various study characteristics, surgical versus non-surgical management, treatment modality, mean follow-up time, analysis methods, and clinical recommendations. Results: Our study included 130 manuscripts. Overall, 110 (85%) reported positive (beneficial) results, three (2%) reported negative results, and 17 (13%) reported no significant difference. Despite only 10/130 studies (8%) having a testable hypothesis, 71 (55%) recommended the use of their studied treatment methods for the patients, five (4%) made recommendations against the use of the studied treatment modality, and 54 (42%) did not make any recommendations. Conclusion: The overall rate for positive outcomes among included manuscripts regarding different treatment methods for Perthes' disease (85%) is higher than the 74% positive outcome rate found among studies for other surgically treated disorders and significantly higher than most scientific literature. Despite the lack of testable hypotheses, most manuscripts recommended their studied treatment method as a successful option for managing patients solely based on the reporting of retrospective data.

Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis.

BACKGROUND: Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE: To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN: Network meta-analysis of comparative studies; Level of evidence, 3. METHODS: A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS: A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION: For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.

A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure.

PURPOSE: Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures. METHODS: A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF. RESULTS: Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026). CONCLUSION: Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail. LEVEL OF EVIDENCE: Prognostic Level III.

Comparison of trends of inpatient charges among primary and revision shoulder arthroplasty over a decade: a regional database study.

Background: This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade. Methods: The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers. Results: During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%. Conclusion: Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Cut-Through versus Cut-Out: No Easy Way to Predict How Single Lag Screw Design Cephalomedullary Nails Used for Intertrochanteric Hip Fractures Will Fail?

Purpose: This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. Materials and Methods: This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radiographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lateral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. Results: No differences in demographics, injury details, fracture classifications, or radiographic parameters were observed between CO/CT cohorts. Of note, a similar rate of post-reduction TAD>25 mm (P=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. Conclusion: The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

Design and evaluation of a 3D printed mechanical balancer for soft tissue balancing in total knee replacement.

PURPOSE: Soft tissue balancing is an important step in a total knee procedure, carried out manually, or using an indicator. The purpose of this study was to evaluate our design of 3D printed Balancer, and demonstrate how it could be used at surgery. PROCEDURES: When inserted between the femur and tibia, the Balancer displayed the forces acting across the lateral and medial compartments, indicated by pointers at the end of the handle. A loading rig was used to measure the pointer deflections for different forces applied at different locations on the condyle surfaces. Repeatability and reproducibilty were evaluated. The Balancer was tested in six fresh knee specimens using a surgical simulation rig. MAIN FINDINGS: Pointer deflections of up to 12 millimeters occurred for less than 1 mm displacements at the condyle surfaces. Reproducibility tests showed a standard deviation of 14% at lower loads, reducing to only 4% at higher loads. Mean pointer deflections were within 8% for forces applied at ±10 mm AP, and +5/-3 mm in an ML direction, relative to the neutral contact point. In specimens, most lateral to medial force differences could be corrected by a 2° change in frontal plane angle of the tibial resection. Effects of ligament releases were also demonstrated. PRINCIPAL CONCLUSIONS: The 3D printed Balancer was easy to use, and provided the surgeon with lateral and medial force data over a full range of flexion, enabling possible corrective procedures to be specified.

Can pain be improved with retention of the posterior cruciate ligament during total knee arthroplasty?

PURPOSE: The purpose of the current study was to determine if differences exist between cruciate-retaining (CR) and posterior-stabilized (PS) implant articulations for total knee arthroplasty (TKA) with regards to early post-operative pain. METHODS: We retrospectively reviewed patients who underwent primary TKA, with the same TKA implant design, at our institution between January 2018 and July 2021. Patients were stratified based on whether they received a CR or non-constrained PS (PSnC) articulation and propensity score matched in a 1:1 ratio. A sub-analysis matching patient who received a constrained PS implant (PSC) to those undergoing CR TKA and PSnC TKA was also carried out. Opioid dosages were converted to morphine milligram equivalents (MME). RESULTS: 616 patients after CR TKA were matched 1:1 to 616 patients with a PSnC implant. There were no significant differences between demographic variables. There were no statistically significant differences in opioid usage measured by MME on post-operative day (POD) 0 (p = 0.171), POD1 (p = 0.839), POD2 (p = 0.307), or POD3 (p = 0.138); VAS pain scores (p = 0.175); or 90-day readmission rate for pain (p = 0.654). A sub-analysis of CR versus PSC TKA demonstrated no significant differences in opioid usage on POD0 (p = 0.765), POD1 (p = 0.747), POD2 (p = 0.564), POD3 (p = 0.309); VAS pain scores (p = 0.293); and 90-day readmission rate for pain (p > 0.9). CONCLUSION: Our analysis demonstrated no significant difference in post-operative VAS pain scores and MME usage based on implant. The results suggest that neither the type of articulation or constraint used for primary TKA has a significant impact on immediate post-operative pain and opioid consumption. LEVEL III EVIDENCE: Retrospective Cohort Study.

Inpatient charges, complication, and revision rates for shoulder arthroplasty in Parkinson disease: a regional database study.

BACKGROUND: Parkinson disease (PD) is an established risk factor for higher rates of complications and revision surgery following shoulder arthroplasty, yet the economic burden of PD remains to be elucidated. The purpose of this study is to compare rates of complication and revisions as well as inpatient charges for shoulder arthroplasty procedures between PD and non-PD patients using an all-payer statewide database. METHODS: Patients undergoing primary shoulder arthroplasty from 2010 to 2020 were identified from the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database. Study groups were assigned based on concomitant diagnosis of PD at the time of index procedure. Baseline demographics, inpatient data, and medical comorbidities were collected. Primary outcomes measured were accommodation, ancillary, and total inpatient charges. Secondary outcomes included postoperative complication and reoperation rates. Logistic regression was performed to evaluate effect of PD on shoulder arthroplasty revision and complication rates. All statistical analysis was performed using R. RESULTS: A total of 39,011 patients (429 PD vs. 38,582 non-PD) underwent 43,432 primary shoulder arthroplasties (477 PD vs. 42,955 non-PD) with mean follow-up duration of 2.9 ± 2.8 years. The PD cohort was older (72.3 ± 8.0 vs. 68.6 ± 10.4 years, P < .001), with greater male composition (50.8% vs. 43.0%, P = .001), and higher mean Elixhauser scores (1.0 ± 4.6 vs. 7.2 ± 4.3, P < .001). The PD cohort had significantly greater accommodation charges ($10,967 vs. $7,661, P < .001) and total inpatient charges ($62,000 vs. $56,000, P < .001). PD patients had significantly higher rates of revision surgery (7.7% vs. 4.2%, P = .002) and complications (14.1% vs. 10.5%, P = .040), as well as significantly higher incidences of readmission at 3 and 12 months postoperatively. After controlling for age and baseline comorbidities, PD patients had 1.64 times greater odds of reoperation compared to non-PD patients (95% CI 1.10, 2.37; P = .012) and a hazard ratio of 1.54 for reoperation when evaluating revision-free survival following primary shoulder arthroplasty (95% CI 1.07, 2.20; P = .019). CONCLUSIONS: PD confers a longer length of stay, higher rates of postoperative complications and revisions, and greater inpatient charges in patients undergoing TSA. Knowledge of the associated risks and resource requirements of this population will aid surgeons in their decision making as they continue to provide care to a growing number of patients affected by PD.

Poor Psychological Readiness Inhibits Return to Play Following Operative Management of Superior-Labrum Anterior-Posterior Tears.

Purpose: The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears. Methods: A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP. Results: The study included 209 athletes who underwent operative management of SLAP tears. A significantly higher percentage of patients who were able to return to play passed the SLAP-RSI benchmark of 56 compared to those who were unable to return (82.3% vs 10.1%; P < .001), and the mean overall SLAP-RSI scores were also significantly higher among those capable of returning to play (76.8 vs 50.0; P < .0001). Additionally, there was a significant difference between the two groups in every component of the SLAP-RSI score (P < .05 for all). Fear of reinjury and the feeling of instability were the most common reasons for not returning to play among contact athletes. Residual pain was the most common complaint among overhead athletes. A binary regression model predicting return to sports was performed, which demonstrated ASES score (odds ratio [OR]: 1.04, 95%; (confidence interval [CI]: 1.01-1.07; P = .009), RTW within 1 month after surgery (OR: 3.52, 95%; CI: 1.01-12.3; P = .048), and SLAP-RSI score (OR: 1.03, 95%; CI: 1.01-1.05; P = .001) were all associated with greater likelihood of return to sports at final follow-up. Conclusions: Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP. Level of Evidence: Level IV, prognostic case series.

Increased 90-Day Readmissions and Complications Following Hip Arthroscopy in Centers With Low Surgical Volume in New York State.

PURPOSE: To (1) classify surgical centers in New York State by volume of hip arthroscopies performed, (2) calculate rates of readmissions and complications by center volume, and (3) identify socioeconomic predictive factors for readmissions and complications following hip arthroscopy. METHODS: Patients who underwent hip arthroscopy at New York State health care facilities from 2010 to 2020 were retrospectively identified using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Hip arthroscopic procedures were identified using the following Current Procedural Terminology codes. Surgical center volumes were classified into 3 categories: low (<85th percentile), medium (85th-95th percentile), and high (>95th percentile). Incidence of readmissions and complications within 90 days was abstracted from SPARCS. Neighborhood socioeconomic status was quantified using the U.S. Area Deprivation Index. Multivariable logistic regression was used to determine whether center volume and other socioeconomic variables were independent predictors of outcomes. RESULTS: In total, 50,252 patients who underwent hip arthroscopy were identified in SPARCS from 2010 to 2020. Of these patients, 13,861 (27.6%) underwent surgery at low-volume centers, 11,757 (23.4%) at medium-volume centers, and 24,634 (49.0%) at high-volume centers. Minorities, publicly insured patients, and patients from lower socioeconomic status neighborhoods made up a larger proportion of cases seen by low-volume centers versus high-volume centers (P < .001). Patients in the low-volume group experienced significantly greater 90-day rates of readmissions (P < .001) and all-cause complications (P < .001) than the other groups. Furthermore, high-volume centers were independently associated with lower odds of readmission (odds ratio 0.57, P < .001) and all-cause complications (odds ratio 0.73, P < .001) versus low-volume centers. CONCLUSIONS: Low-volume surgical centers are associated with increased readmission and complication rates following hip arthroscopy, independent of other socioeconomic factors such as age, sex, race, insurance status, and neighborhood socioeconomic status. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.