Anatomic total shoulder arthroplasty with inlay glenoid component: A systematic review.

Background: A total shoulder arthroplasty (TSA) system utilizing an inlay glenoid component has been proposed as a means of reducing glenoid component loosening while still providing patients with desirable functional and clinical outcomes. The purpose of this study was to systematically review current outcomes literature on TSA using an inlay glenoid component. Methods: A literature search was conducted using PubMed/MEDLINE, Cochrane Database of Systematic Reviews, and Web of Science databases. Studies comparing pre- and postoperative functional and clinical outcomes were included. Results: Five studies with 148 shoulders (133 patients) were included. Patient-reported outcomes improved, including the American Shoulder and Elbow Surgeons score (mean change 34.1 to 80.6), Penn Shoulder Score (mean change 43.3 to 85.5), Single Assessment Numeric Evaluation score (mean change 34.1 to 80.6), and visual analog scale-pain (mean change 6.9 to 1.6). Range of motion improved for forward elevation (mean change 109.6 to 156.2) and external rotation (mean change 21.5 to 50.8). Glenoid component loosening occurred in one shoulder (0.68%). Two revision surgeries (1.35%) were performed. Discussion: The use of an inlay glenoid component is associated with improvements in postoperative pain, function, and satisfaction while minimizing rates of glenoid component loosening and the need for revision surgery over short-term follow-up. Level of evidence: systematic review, level IV.

Outcomes of the Latarjet procedure in female patients: A case series and matched-pair analysis.

Background: The objective of this study was to retrospectively report on the outcomes of female patients undergoing the Latarjet procedure. Methods: Female patients undergoing the Latarjet procedure with minimum 1 year follow-up were identified and contacted to obtain Numeric Pain Rating Scale (NPRS), Subjective Shoulder Value (SSV), and return to sport (RTS) data. Eligible females were then matched 1:1 with a male counterpart based on laterality and age (± 3 years), and outcomes compared. Results: A total of 20 female patients with a mean follow-up of 73.8 months reported postoperative NPRS and SSV scores of 2.2 ± 2.3 and 69.3 ± 22.0, respectively. Of the nine athletes, 3 (33%) reported a successful RTS at a mean of 9 months. Four patients (20.0%) required reoperation at a mean of 27.1 months. The matched analysis demonstrated similar NPRS scores between male and female patients and a trend towards lower SSV scores and rates of RTS. Conclusion: At mid-term follow-up female patients reported pain levels similar to female-specific literature reports, but overall low subjective shoulder function and RTS. Compared to propensity-matched males, females reported similar levels of pain, lower shoulder function, and lower rates of RTS, however, differences did not reach statistical significance. Level of Evidence: IV, retrospective case series.

Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial (RCT). OBJECTIVE: Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA: Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS: This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS: Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS: A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.

Clinical and radiographic outcomes of the modified McLaughlin procedure for locked posterior dislocation of the shoulder: a systematic review.

Background: Multiple treatment options for locked posterior dislocation of the shoulder (LPDS) have been described, including the modified McLaughlin procedure. The purpose of this review, therefore, was to perform a systematic review of the literature to synthesize the available data reporting on the clinical and radiographic outcomes of patients undergoing the modified McLaughlin procedure for the treatment of LPDS. Methods: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases from inception through January 2023 was performed. Outcomes studies reporting on clinical and radiographic outcomes in patients undergoing the modified McLaughlin procedure for LPDS were included. Postoperative complications and episodes of recurrent instability were noted. Results: A total of 1322 studies were initially identified, of which 9 were deemed eligible for inclusion in our review. Among included studies, a total of 97 shoulders (96 patients) with a mean age of 37.7 years (range, 26-51) were identified. The most common mechanisms of injury included trauma, seizure, and electrocution. Reverse Hill-Sachs lesions ranged in size from 20% to 50% of the humeral head articular surface. At final follow-up, the weighted mean University of California at Los Angeles shoulder score, Constant-Murley Score, American Shoulder and Elbow Surgeons shoulder score, and visual analog scale for pain score were 29 (range, 27-31), 75 (range, 65-92), 92 (range, 83-98), and 1.9 (range, 1-2.4), respectively. Postoperative Constant-Murley Score and University of California at Los Angeles scores were highest in the one study reporting exclusively on treatment during the acute period. Weighted mean postoperative forward flexion, abduction, external rotation, and internal rotation were 154° (range, 102-176), 144° (range, 118-171), 64° (range, 44-84), and 47° (range, 42-56), respectively. Osteointegration of the lesser tuberosity was noted in all patients at the final follow-up. Postoperative complications occurred in one patient (1.0% of cohort); a screw migration successfully treated with operative removal. Recurrent instability was noted in two epileptic patients (2.1% of cohort). Conclusion: The literature surrounding the use of the modified McLaughlin procedure for LPDS remains sparse. This review demonstrates that this procedure is associated with favorable clinical and radiographic outcomes with overall low rates of complication and recurrent instability, especially when the time from injury to surgery is minimized. These findings illustrate that in patients presenting with LPDS and a reverse Hill-Sachs lesion between 20% and 50% of the humeral head articular surface, the modified McLaughlin procedure is a safe and effective treatment option.

Size and morphology of the coracoid and glenoid in pediatric and adolescent patients: implications for Latarjet procedure.

Background: Glenohumeral instability is a challenging problem in children and adolescents. For patients with anterior glenoid bone loss, the Latarjet procedure is an effective treatment option. However, concerns about coracoid size and morphology may limit its utilization within this patient population. The purpose of this study was to establish normative data on coracoid and glenoid size and morphology among a large cohort of adolescent patients and describe the anatomic relationships with demographic factors. Methods: This is a retrospective cross-sectional study of a consecutive series of 584 patients aged 12-21 years after a chest computed tomography scan for non-shoulder related trauma at a single level I trauma center. Demographic characteristics were collected from the electronic medical record, and the following coracoid anatomic measurements were obtained from computed tomography scans: coracoid length, coracoid thickness, coracoid width, glenoid height, and glenoid width. The ratio of coracoid thickness to glenoid width was calculated to estimate the percent bone loss that could be addressed with a traditional Latarjet coracoid transfer. To ensure reliability among 3 reviewers, all measured the same 25 scans and inter-rater reliability was excellent with all Kappa coefficients >0.81. The remaining scans were divided equally and assessed separately by these reviewers. Correlation coefficients were used to quantify the relationships between all anatomic measures and the age, weight, and height of individuals. Growth curves for each measurement were modeled using quantile regression with height and height∗height as predictors. Additionally, we stratified the growth curves by sex, when significant. Of the 584 subjects, 55% were male, and average age was 19 years (range 12, 21). Results: All growth curves illustrated increase anatomic size across the height range of 145-190 cm. The growth curve including all patients (Fig. 1) illustrated that the 50% percentile of median coracoid length increased from approximately 28 to 32 mm. In addition to height, sex was a significant predictor for coracoid width and glenoid width. The median coracoid width increased from approximately 9.5 to 10.2 mm for females compared to an increased width from approximately 10 to 11 mm for males. The median glenoid width for females increased from approximately 21 to 25 mm and for males the median glenoid width increased from just under 22 to 25.5 mm. Conclusions: Among children and adolescents, coracoid and glenoid size are correlated with patient height. These data can help guide patient selection for the Latarjet procedure.

Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids.

The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.

Healthcare costs of failed rotator cuff repairs.

Background: The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States. Methods: A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period. Results: The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure. Conclusion: The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted. Clinical Relevance: Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty.

BACKGROUND: We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway. METHODS: This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups. RESULTS: At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results. CONCLUSIONS: A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears. METHODS: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included. RESULTS: A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty. CONCLUSION: Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

Onlay versus inlay humeral components in reverse shoulder arthroplasty: A systematic review and meta-analysis.

Background: Advances have been made to the traditional inlay Grammont Reverse Shoulder Arthroplasty (RSA) design such as the onlay humeral component prosthesis. Currently, there is no agreement in the literature regarding the best option for the humeral component when comparing inlay and onlay designs. This review compares the outcomes and complications between onlay versus inlay humeral components for RSA. Methods: A literature search was conducted using PubMed and Embase. Only studies reporting outcomes comparing onlay versus inlay RSA humeral components were included. Results: Four studies with 298 patients (306 shoulders) were included. Onlay humeral components were associated with better external rotation (ER) (p < 0.0001). No significant difference in forward flexion (FF) or abduction was found. Constant scores (CS) and VAS scores did not differ. Increased scapular notching was found in the inlay group (23.18%) versus the onlay group (7.74%) (p = 0.02). Postoperative scapular fractures and acromial fractures did not differ. Conclusion: Onlay and inlay RSA designs are associated with improved postoperative range of motion (ROM). Onlay humeral designs may be associated with greater ER and lower rate of scapular notching; however, no difference was found in Constant and VAS scores, so further studies are required to assess the clinical significance of these differences.

Opioid-Free Forefoot Surgery vs Traditional Perioperative Opiate Regimen: A Randomized Controlled Trial.

BACKGROUND: In response to the opioid epidemic, the use of multimodal pain management in orthopaedic surgery is increasing. Efforts to decrease opioid prescribing and opioid consumption among foot and ankle surgical patients are needed. The purpose of this study was to compare the efficacy and adverse events between 2 multimodal pain management pathways for forefoot surgical patients: standard opioid-containing (OC) and opioid-free (OF). METHODS: This is a single-center noninferior randomized controlled trial of 51 patients undergoing forefoot surgery allocated to one of 2 perioperative pain management treatments: opioid-free, multimodal (OF, n=27 patients), or traditional opioid-containing (OC, n=24 patients). Patient characteristics, creatine markers, pain (numeric rating scale [NRS]), general health (Veterans Rand 12-Item Health Survey [VR-12]), and depression were measured preoperatively. Postoperatively, pain was measured at 24-hour, 2-week, and 6-week time points. Satisfaction with pain control, complications, and general health were measured at 2 and 6 weeks. RESULTS: The OF group is statistically noninferior to the OC group and reported lower median pain scores at 24 hours (2 [IQR 0, 3] vs 6 [IQR 3.5, 7]; p<.0001) and 2 weeks (2 [IQR 1, 4] vs 4 [IQR 0, 3]; p=.018]. By 6 weeks, pain levels were similar between groups. More than 85% of all patients reported satisfaction with pain level at 2 weeks, which increased to >90% at 6 weeks. The VR-12 scores were similar between groups across all time points. At 2 weeks, 8 patients in each group reported constipation. By 6 weeks, all but 2 OC patients reported resolution. No other adverse events of postoperative wound complications, readmissions, medication reactions, thrombosis, or persistent pain were documented. CONCLUSION: In forefoot surgery, the opioid-free pain management protocol was statistically noninferior to the opioid-containing protocol in reducing postoperative pain. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature.

PURPOSE: To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020. METHODS: A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up. RESULTS: A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months. CONCLUSIONS: Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR. LEVEL OF EVIDENCE: Level IV, a systematic review of Level III-IV studies.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting.

OBJECTIVE: The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN: A prospective observational study. SETTING: One large healthcare system. PATIENTS AND PARTICIPANTS: Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS: A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE: The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS: A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION: Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis.

BACKGROUND: Rotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA. AIM: To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA. METHODS: This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected. RESULTS: A total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes. CONCLUSION: Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Trends in Repair vs. Biceps Tenodesis for Superior Labrum From Anterior to Posterior (SLAP) Tear: An Epidemiological Study.

Background The purpose of this epidemiologic study was to report general trends in the number of superior labrum from anterior to posterior (SLAP) tear repairs and biceps tenodesis performed along with the patient and hospital characteristics within the period of 2016-2018. Methods National Ambulatory Surgery Sample (NASS) database was used as the source of data for this epidemiologic study of the United States population. Current Procedural Terminology (CPT) codes were utilized to identify patients that underwent SLAP repair or biceps tenodesis between 2016 and 2018. Results The national estimates of encounters from the NASS database reported 29,931 SLAP repairs in 2016 and each subsequent year saw a decline to 26,509 repairs in 2017 and 23,451 repairs in 2018 (p<0.0001). Conversely, in 2016 there were 19,221 biceps tenodeses and each subsequent year saw an increase to 21,625 biceps tenodeses in 2017 and 22,867 biceps tenodeses in 2018 (p<0.0001). Conclusion The results of our epidemiologic study found that the total number of SLAP repairs is decreasing while biceps tenodesis is increasing. SLAP repairs were performed for younger patients and biceps tenodeses were performed for older patients. This study demonstrates that clinical practice reflective of recent evidence regarding optimal age for SLAP repair is slow to change. While there is ongoing debate as to the gold standard for the surgical management of SLAP tear lesions, our study confirms that there is an increasing trend among orthopedic surgeons favoring biceps tenodesis which may reflect the increasing literature evidence supporting better clinical outcomes after biceps tenodesis compared to SLAP repair.

Comorbidity scores reported in anatomic and reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Due to the aging population, the number of reverse shoulder arthroplasty (RSA) and anatomic shoulder arthroplasty (TSA) continue to increase annually. Although outcome measures are frequently reported in literature for patients who undergo shoulder arthroplasty, no studies have analyzed reporting of patient comorbidities in this population. The purpose of this study was to evaluate reporting of comorbidity indices in shoulder arthroplasty literature and assess how this reporting may inform management and outcomes. METHODS: A database was compiled systematically using PubMed to identify articles pertaining to shoulder arthroplasty published between 2019 and 2021. The search terms, "reverse shoulder arthroplasty" and "anatomic shoulder arthroplasty," were used to identify clinical studies. Non-clinical (e.g., translational and basic science) and review articles were excluded. Included studies were then analyzed for reporting of comorbidity indices. RESULTS: A total of 199 articles were included in this review and reported comorbidities. Of these, 15.6% (31 of 199) pertained to TSA, while 84.4% (168 of 199) pertained to RSA. Within this review, 57.8% (115 of 199) articles utilized comorbidity scores, while 42.2% (84 of 199) reported only comorbid diagnoses. Among the scores utilized, the American Society of Anesthesiologists (ASA) physical status classification system was the most widely used among both the TSA (52.9%, 9 of 17) and the RSA studies (58.2%, 57 of 98). Additional scores within the RSA literature included the Charlson Comorbidity Index (CCI) (35.3%, 6 of 17), the Charlson Comorbidity Index by Deyo et al. (J Clin Epidemiol. 45(6):613-9, 1992) (CCI-Deyo; 5.9%, 1 of 17), the Modified Charlson Comorbidity Index (modified-CCI) (5.9%, 1 of 17), the Elixhauser et al. (Med Care. 36(1):8-27, 1998) Comorbidity Measure (ECM) (11.8%, 2 of 17), and the Modified Frailty Index (mFI) (5.9%, 1 of 17). With the TSA literature, the additional comorbidity scores included the CCI (30.6%, 30 of 98), the CCI-Deyo (6.1%, 6 of 98), the modified-CCI (1.0%, 1 of 98), the ECM (8.2%, 8 of 98), the Factor-5 modified Frailty Index (mFI-5) (1.0%, 1 of 98), and the mFI (1.0%, 1 of 98). CONCLUSION: The reporting of comorbidity indices is an important factor when considering patient outcomes and complications reported in shoulder arthroplasty literature. Although the reporting of these scores appears to be more prevalent in current literature, there is no standard or consistency in terms of which scores are reported. Given this diversity in comorbidity scores, further research is necessary to develop a single standardized score to properly analyze the effect of comorbidities on shoulder arthroplasty patient outcomes.

Distal Biceps Repairs in Females: A Large Single-Center Case Series.

Background: Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown. Questions/Purpose: We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology. Methods: A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS). Results: Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20). Conclusion: This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Distal Clavicle Excision: An Epidemiologic Study Using the National Ambulatory Surgery Sample Database.

BACKGROUND: This study aimed to examine national trends pertaining to patient demographics and hospital characteristics among distal clavicle excision (DCE) procedures performed in the United States. METHODS: The National Ambulatory Surgery Sample (NASS) database was queried for data. Encounters with Current Procedural Terminology (CPT) code 29824 were selected. Metrics derived from these encounters included patient demographic information such as age, geographic location, median household income per zip code, and primary expected insurance payer. Hospital characteristics derived included total charges for DCE procedures, location of the hospital, disposition of the patient, hospital census region, control/ownership of the hospital, and location/teaching status of the hospital. The proportion of DCE performed concomitantly with rotator cuff repair (RCR) was also analyzed. P-values were obtained from continuous variables using a t-test with a linear regression model. P-values were obtained from event variables using chi-square analysis. RESULTS: The incidence of arthroscopic DCE in the US decreased from 99,070 in 2016 to 93,678 (5.5%) in 2018. Of note, the proportion of DCE performed concomitantly with RCR significantly increased from 50.4% in 2016 to 52.8% in 2018 (P < 0.0001). Median patient age increased from 2016 to 2018 (56.4 to 57.2; P < 0.0001). The income quartile that saw the highest number of encounters was between $43,000 and $53,999 (P < 0.0001). Hospital trends display an increasing cost from $16,944 to $18,855 over the study period (P = 0.0016). Private insurance, including health maintenance organizations (HMOs), were the largest payers for this procedure; however, a decreasing trend in DCE covered by private insurance was noticed (50.2% to 47.3%; P < 0.0001). Medicare was the second-largest payer ranging from 27.9% in 2016 to 29.9% in 2018. The urban teaching model of hospitals continues to see the highest number of encounters for this procedure. CONCLUSIONS: In both 2016 and 2018, private insurance was the most common payer, most DCEs were performed in urban teaching hospitals, and most patients undergoing the procedure had a median household income between $43,000 and $59,000. Between 2016 and 2018, there was a significant increase in costs associated with DCE, as well as an increase in the median age of patients undergoing the procedure. The proportion of DCE performed concurrently with RCR also significantly increased during the study period.

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway.

BACKGROUND: Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty. METHODS: This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed. RESULTS: Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P = .003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P < .001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P = .006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium. CONCLUSION: A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

Revision total elbow arthroplasty using intramedullary strut allograft for aseptic loosening of the humeral stem.

Total elbow arthroplasty (TEA) has become a well-accepted treatment option for many pathologies of the elbow joint. Its use in distal humerus fractures in elderly patients has become increasingly popular and has good clinical results. However, with the aging population and the increasing number of TEAs performed, so comes the potential for an increasing number of revision TEA cases. Revision TEA can be extremely challenging. In addition to the technical difficulties of safe exposure and implant removal, reimplantation of a cemented humeral component with loss of bone stock can be a challenging step in this procedure. The purpose of this article was to describe a novel technique to address aseptic loosening of the humeral stem and loss of humeral bone stock with revision of the humeral component using a long-stemmed cemented implant and intramedullary allograft fibular strut bone grafting.