The State of Synthetic Cannabinoid Medications for the Treatment of Pain.

Synthetic cannabinoids are compounds made in the laboratory to structurally and functionally mimic phytocannabinoids from the Cannabis sativa L. plant, including delta-9-tetrahydrocannabinol (THC). Synthetic cannabinoids (SCs) can signal via the classical endogenous cannabinoid system (ECS) and the greater endocannabidiome network, highlighting their signalling complexity and far-reaching effects. Dronabinol and nabilone, which mimic THC signalling, have been approved by the Food and Drug Administration (FDA) for treating nausea associated with cancer chemotherapy and/or acquired immunodeficiency syndrome (AIDS). However, there is ongoing interest in these two drugs as potential analgesics for a variety of other clinical conditions, including neuropathic pain, spasticity-related pain, and nociplastic pain syndromes including fibromyalgia, osteoarthritis, and postoperative pain, among others. In this review, we highlight the signalling mechanisms of FDA-approved synthetic cannabinoids, discuss key clinical trials that investigate their analgesic potential, and illustrate challenges faced when bringing synthetic cannabinoids to the clinic.

Understanding the epidemiology and perceived efficacy of cannabis use in patients with chronic musculoskeletal pain.

BACKGROUND: The belief that cannabis has analgesic and anti-inflammatory properties continues to attract patients with chronic musculoskeletal (MSK) pain towards its use. However, the role that cannabis will play in the management of chronic MSK pain remains to be determined. This study examined 1) the rate, patterns of use, and self-reported efficacy of cannabis use among patients with chronic MSK pain and 2) the interest and potential barriers to cannabis use among patients with chronic MSK pain not currently using cannabis. METHODS: Self-reported cannabis use and perceived efficacy were prospectively collected from chronic MSK pain patients presenting to the Orthopaedic Clinic at the University Health Network, Toronto, Canada. The primary dependent variable was current or past use of cannabis to manage chronic MSK pain; bivariate and multivariable logistic regression were used to identify patient characteristics independently associated with this outcome. Secondary outcomes were summarized descriptively, including self-perceived efficacy among cannabis users, and interest as well as barriers to cannabis use among cannabis non-users. RESULTS: The sample included 629 patients presenting with chronic MSK pain (mean age: 56±15.7 years; 56% female). Overall, 144 (23%) reported past or present cannabis use to manage their MSK pain, with 63.7% perceiving cannabis as very or somewhat effective and 26.6% considering it as slightly effective. The strongest predictor of cannabis use in this study population was a history of recreational cannabis use (OR 12.7, p<0.001). Among cannabis non-users (N=489), 65% expressed interest in using cannabis to manage their chronic MSK pain, but common barriers to use included lack of knowledge regarding access, use and evidence, and stigma. CONCLUSIONS: One in five patients presenting to an orthopaedic surgeon with chronic MSK pain are using or have used cannabis with the specific intent to manage their pain, and most report it to be effective. Among non-users, two-thirds reported an interest in using cannabis to manage their MSK pain, but common barriers to use existed. Future double-blind placebo-controlled trials are required to understand if this reported efficacy is accurate, and what role, if any, cannabis may play in the management of chronic MSK pain.

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis.

BACKGROUND: The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature. METHODS: MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery. RESULTS: Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials' findings no longer statistically significant. CONCLUSION: Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.

Glenoid bone loss in shoulder arthroplasty: a narrative review.

Background and Objective: Crucial to the success of any total or reverse shoulder arthroplasty (RSA) is the stability of the glenoid component fixation. Instability can lead to early implant failure and unsatisfactory results. Patients often present with varying forms of glenoid bone loss (GBL) in both the primary and revision settings, which can be a challenge for the treating surgeon. Severe cases of GBL can increase the risk of potential complications and diminish implant longevity. The use of the reverse total shoulder replacement has been particularly helpful when addressing significant glenoid bony defects. Various approaches have been proposed to deal with GBL, all of which require an individualized assessment of the specifics of the defect in order to provide maximal fixation and thereby optimize the longevity of the shoulder arthroplasty. This article aims to review the recent literature on GBL in shoulder arthroplasty to provide guidance when considering treatment based on the best available evidence. Methods: PubMed, MEDLINE, EMBASE, AccessMedicine, ClinicalKey, DynaMed, and Micromedex were queried for publications utilizing the following keywords: "glenoid bone loss" AND "glenoid bone deficiency" AND "shoulder arthroplasty" AND "classification". The search was restricted to research published between 2004 and 2023. There were no restrictions on study type or language. Key Content and Findings: GBL should be critically evaluated prior to undertaking total shoulder arthroplasty (TSA). The treating surgeon should be aware of various methods of addressing bone defects. Conclusions: The use of TSA is increasing to address various shoulder pathologies. Addressing glenoid bone defects is of critical importance to maximize the longevity and outcome of TSA.

The Continuous Fragility Index of Statistically Significant Findings in Randomized Controlled Trials That Compare Interventions for Anterior Shoulder Instability.

BACKGROUND: Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes. PURPOSE: To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors. RESULTS: There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes (r = 0.23 [95% CI, 0.13-0.33]; P < .001). CONCLUSION: More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs.

Imaging in an academic orthopedic shoulder service: a report on incidental lung pathology findings.

INTRODUCTION: Computed tomography (CT) is often utilized for both diagnostic and pre-operative planning purposes in shoulder arthroplasty. Our study reports on the incidence of pulmonary findings in our pre-operative shoulder arthroplasty population over 14 years at our institution. METHODS: We conducted a retrospective review of all "shoulder CT" exams ordered by two orthopedic upper extremity surgeons between the years of 2008 and 2021. These exams were then further analyzed to include only those ordered for the purpose of pre-operative "shoulder arthroplasty" planning. All incidental findings were documented and those with pulmonary findings were then further analyzed. A detailed chart review was then performed on these patients to determine the impact on their planned shoulder arthroplasty. RESULTS: A total of 363 shoulder pre-operative CTs were ordered by our two upper extremity orthopedic surgeons at our institution between the years of 2008 and 2021. Primary lung cancer in the form of adenocarcinoma (n = 3) had an incidence of 0.8% of all CT scans and 1.4% of all pulmonary incidental findings. Fifteen patients (4% of all CT scans and 7% of all pulmonary incidental findings) had no concern for malignancy and were appropriately evaluated with further imaging based on their initial shoulder CT. CONCLUSION: While shoulder arthroplasty and pre-operative planning with CT imaging continue to become more common, so too is the incidence of reported pulmonary findings. From a patient care standpoint, it is important that these findings are accurately identified, appropriately triaged, and communicated clearly to our patients.

Surgical treatment options for articular cartilage defects of the glenohumeral joint: A systematic review.

Background: Many joint-preserving surgical interventions for cartilage defects of the knee have been adapted for use in the shoulder; however, there still exists no clear consensus for treatment. Thus, the purpose of this systematic review was to evaluate the outcomes of different interventions in patients with focal chondral lesions of the glenohumeral joint. Methods: A literature search was conducted using PubMed, Embase, and Medline. Patients who underwent a joint-preserving surgical procedure to treat a focal chondral defect of the glenoid, humeral head or both were included. Patients treated for diffuse cartilage defects or with shoulder arthroplasty were excluded. Results: Ten studies were included, with follow-up data available for 194 shoulders. Eight joint-preserving procedures were evaluated, with microfracture being the most common. One study evaluating microfracture reported significant improvements in patient-reported outcomes at short-term and long-term follow-up compared to preoperative scores. Across all studies, 32 patients underwent subsequent shoulder surgery, with 22 being arthroplasties. Conclusions: We found improvements in patient-reported and functional outcomes across all studies. Although joint-preserving procedures have shown reasonable outcomes for focal chondral defects of the glenohumeral joint, long-term outcomes remain unknown, and the progression of osteoarthritis remains a concern. Higher quality evidence is required to make definitive recommendations. Level of Evidence: IV.

Variability in quantifying the Hill-Sachs lesion: A scoping review.

Background: Currently, is there no consensus on a widely accepted measurement technique for calculating the Hill-Sachs lesion (HSL). The purpose of this review is to provide an overview of the techniques and imaging modalities to assess the HSL pre-operatively. Methods: Four online databases (PubMed, Embase, MEDLINE, and COCHRANE) were searched for literature on the various modalities and measurement techniques used for quantifying HSLs, from data inception to 20 November 2021. The Methodological Index for Non-Randomized Studies tool was used to assess study quality. Results: Forty-five studies encompassing 3413 patients were included in this review. MRA and MRI showed the highest sensitivity, specificity, and accuracy values. Intrarater and interrater agreement was shown to be the highest amongst MRA. The most common reference tests for measuring the HSL were arthroscopy, radiography, arthro-CT, and surgical techniques. Conclusion: MRA and MRI are reliable imaging modalities with good test diagnostic properties for assessment of HSLs. There is a wide variety of measurement techniques and imaging modalities for HSL assessment, however a lack of comparative studies exists. Thus, it is not possible to comment on the superiority of one technique over another. Future studies comparing imaging modalities and measurement techniques are needed that incorporate a cost-benefit analysis.

Comparing surgical outcomes of anterior capsular release vs circumferential release for persistent capsular stiffness.

Purpose: To consolidate the existing literature evaluating anterior capsular release and circumferential capsular release in the treatment of adhesive capsulitis (AC) of the shoulder. Methods: The electronic databases PUBMED, EMBASE, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) were searched from data inception to October 8, 2020. Data are presented descriptively where appropriate. A meta-analysis was conducted for patient-reported outcomes. Results: Overall, there were forty-six articles included. The majority of patients underwent circumferential release compared to anterior release (80.1% vs. 19.9%). Concomitant Manipulation Under Anesthesia (MUA) was employed in 25 studies, with a higher occurrence in the anterior compared to the circumferential release group (70% vs 60%). Both groups experienced significant improvements postoperatively in range of motion (ROM) and patient-reported outcomes. Complication rates were low for both anterior release (0.67%) and 360° release (0.44%). Conclusion: Both anterior and circumferential release are effective techniques for treating AC with low complication rates. Future studies should improve documentation of patient demographics, surgical techniques and outcomes to determine an individualized treatment protocol for patients. Level of evidence: Level IV, Systematic Review of Level I-IV studies.

A comprehensive comparison and evaluation of surgical techniques for anterior shoulder instability: a Bayesian network meta-analysis.

BACKGROUND: Anterior shoulder instability is a common clinical problem; however, conflicting evidence exists regarding optimal treatment algorithms. We perform a comparative analysis of stabilization techniques used for recurrent anterior shoulder instability to identify the one associated with the lowest rate of recurrent instability. We additionally explore how glenoid bone loss and osseus lesions affect recurrence rates. METHODS: PubMed, MEDLINE, Embase, and Cochrane databases were searched for clinical studies comparing surgical techniques for anterior shoulder instability. Two team members independently assessed all potential studies for eligibility and extracted data. Each included study underwent a risk of bias assessment using the Cochrane risk of bias summary tool. The primary outcome of interest was the rate of recurrent instability, which underwent a Bayesian network meta-analysis. Additional analyses were performed relating to the degree of glenoid bone loss and the presence of osseous lesions. RESULTS: Of 2699 studies screened, 52 studies with 4209 patients were included. Patients who underwent open Latarjet demonstrated the overall lowest rate of recurrent instability [log odds ratio (LOR) 1.93], whereas patients who underwent arthroscopic Bankart repair demonstrated the highest (LOR 2.87). When glenoid bone loss was 10% to 20%, open Latarjet had significantly lower recurrent instability (P = .0016) compared to arthroscopic Bankart repair. When glenoid bone loss increased from 0%-10% to 10%-20%, arthroscopic Bankart repair had a significantly increased rate of recurrence (P = .021). In the presence of an engaging Hill-Sachs lesion, both open Latarjet (P = .01) and arthroscopic Bankart with remplissage (P = .029) had significantly reduced recurrence rates compared to arthroscopic Bankart repair. Finally, regardless of procedure, the presence of a Hill-Sachs or bony Bankart lesion was associated with an increased risk of recurrent instability (r = 0.44, P = .0003, and r = 0.40, P = .006, respectively). CONCLUSION: The open Latarjet has the overall lowest recurrent instability and significantly lower compared to arthroscopic Bankart repair in the setting of increasing glenoid bone loss. Bone loss between 0% and 10% results in similar outcomes across all procedures.

The role of preoperative opioid use in shoulder surgery-A systematic review.

Background: Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. Methods: EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Results: Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Conclusion: Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients. Level of evidence: Level IV, Systematic review.

An Analysis of Shoulder Surgeon Volume on Surgeon Competency, Hospital Costs, and Adverse Events: A Systematic Review.

Purpose: The purpose of this systematic review is to assess the impact of shoulder surgeon volume of common shoulder procedures on hospital/surgeon efficiency, adverse events, and hospital costs. Methods: Four online databases (PubMed, Embase, MEDLINE, and CENTRAL) were searched for literature on the influence of surgeon volume on outcomes for shoulder surgery, from data inception to October 1, 2020. The Methodological Index for Non-Randomized Studies tool was used to assess study quality. Data are presented descriptively. Results: Twelve studies encompassing 150,898 patients were included in this review. The distribution of surgery type was rotator cuff repair (53.7%; n = 81,066), shoulder arthroplasty (35.7%; n = 53,833), and ORIF (10.6%; n = 15,999). Higher surgeon volume for rotator cuff repairs was associated with lower surgical time, length of stay, costs, and reoperation/readmission rates. For shoulder arthroplasty, higher surgeon volume was associated with lower length of stay, costs, surgical time, non-routine disposition, blood loss, reoperation/readmission, and complications. As for ORIF, higher surgeon volume was associated with lower length of stay, costs, and complications. Conclusion: A high surgical volume leads to improved results for hospital/surgeon efficiency and reduces adverse events and hospital costs across various orthopaedic procedures. Hospitals and physicians can use this information to develop and adhere to policies and practices that contribute to more efficient and better-quality care for patients. Level of Evidence: III.

Medical Cannabis Use and Inflammatory Cytokines and Chemokines Among Adult Chronic Pain Patients.

Background: Utilizing cannabis as a therapeutic option for chronic pain (CP) has increased significantly. However, data regarding the potential immunomodulatory effects of cannabis in CP patients remain scarce. We aimed at exploring the relationship between cannabis use and inflammatory cytokines and chemokines among a cohort of CP patients. Methods: Adult patients with a CP diagnosis and medical authorization of cannabis were enrolled. Patients completed validated clinical questionnaires and self-reported the effectiveness of cannabis for symptom management. Patients' blood and cannabis samples were analyzed for the presence of four major cannabinoids, two major cannabinoid metabolites, 29 different cytokines/chemokines, and cortisol. The multivariable linear regression model was used to identify cannabis and patient factors associated with immune markers. Results: Fifty-six patients (48±15 years; 64% females) were included, with dried cannabis (53%) being the most common type of cannabis consumed. Seventy percent of products were considered delta-9-tetrahydrocannabinol (Δ9-THC)-dominant. The majority of patients (96%) self-reported effective pain management, and 76% reported a significant decrease in analgesic medication usage (p≤0.001). Compared with males, female patients had higher plasma levels of cannabidiol (CBD), cannabidiolic acid, Δ9-THC, and 11-hydroxy-Δ9-tetrahydrocannabinol but lower concentrations of delta-9-tetrahydrocannabinolic acid and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH). Females had significantly lower eotaxin levels (p=0.04) in comparison to male patients. The regression analysis indicated that high cannabis doses were related to increased levels of interleukin (IL)-12p40 (p=0.02) and IL-6 (p=0.01), whereas female sex was associated with decreased eotaxin (p≤0.01) concentrations. Blood CBD levels were associated with lower vascular endothelial growth factor (p=0.04) concentrations, and THC-COOH was a factor related to decreased tumor necrosis factor alpha (p=0.02) and IL-12p70 (p=0.03). Conclusion: This study provides further support for the patient-perceived effectiveness of cannabis in managing CP symptoms and reducing analgesic medication consumption. The results suggest a potential sex difference in metabolizing cannabinoids, and the varying immune marker concentrations may support a possible immunomodulatory effect associated with patient sex and cannabis product type. These preliminary findings provide grounds for further validation using larger, well-designed studies with longer follow-up periods.

A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty.

Background: Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. The aim of this study was to investigate literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty. Methods: We conducted a systematic review of Medline, Embase and Cochrane Library databases from inception to 6 April 2020. Methodological quality was assessed using MINORS and GRADE criteria. Results: We included 17 studies, with 11 included in meta-analyses and 6 in narrative review. A meta-analysis of hospital readmissions demonstrated no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, p = 0.49). Pooled post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70, p = 0.02). Considerable cost saving of between $3614 and $53,202 (19.7-69.9%) per patient were present in the outpatient setting. Overall study quality was low and presented a serious risk of bias. Discussion: Shoulder arthroplasty in the outpatient setting appears to be as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. However, this is based on low quality evidence and high risk of bias suggests further research is needed to substantiate these findings.

Assessing Bone Loss in the Unstable Shoulder: a Scoping Review.

PURPOSE OF REVIEW: The aim of this scoping review is to identify and summarize findings published in the literature over the past 5 years related to methods for assessment of bone loss in anterior shoulder instability. RECENT FINDINGS: Of the 113 clinical studies included in this review, 76 reported a cutoff for glenoid bone loss when determining the patients indicated for one of the many stabilization procedures investigated. Bone loss on the glenoid side was evaluated most commonly with three-dimensional computed tomography (3D CT), and either linear or surface area-based methods were employed with the use of a best-fit circle. When combined with plain CT, the two methods comprise up to 70% of the reported measurement techniques for glenoid bone loss (79 of 113 studies). On the humeral side, Hill-Sachs lesions were assessed more heterogeneously, though plain CT or 3D CT remained the methods of choice in the majority of studies (43 of 68, 63.2%). Lastly, the glenoid track was assessed by 27 of 113 studies (23.9%), again most commonly with 3D CT (13 studies) and plain CT (seven studies). The assessment of glenoid and humeral bone loss is essential to treatment decisions for patient with recurrent anterior shoulder instability. Glenoid bone loss is most commonly assessed using cross-sectional imaging, most often 3D CT, and some variation of a best-fit circle applied to the inferior portion of the glenoid. Hill-Sachs lesion assessment was also commonly done using three-dimensional imaging; however, there was more variability in assessment methods across studies and there is an obvious need to unify the approach to humeral bone loss assessment for the purposes of improving treatment decisions and to better assess on-track and off-track lesions.

Anatomic total shoulder arthroplasty in rheumatoid arthritis: A systematic review.

Purpose: Given the poor soft-tissue quality in rheumatoid arthritis patients, many believe that rheumatoid arthritis should be treated with reverse total shoulder arthroplasty (rTSA). The purpose of this paper is to systematically assess outcomes of anatomic total shoulder arthroplasty (aTSA) in rheumatoid arthritis to determine if aTSA remains a viable option. Methods: A comprehensive literature search was conducted identifying articles relevant to aTSA in the setting of rheumatoid arthritis with intact rotator cuff. Outcomes include clinical outcomes and rates of complication and revision. Results: Ten studies were included with a total of 279 shoulders with mean follow-up of 116 ± 69 months. The mean age was 68 ± 10 years. Survivorship was 97%, 97% and 89% at 5, 10 and 20 years, respectively. The overall complication rate was 9%. Radiolucency was present in 69% of patients, of which 34% were at risk of loosening at 79 months. The overall rate of revision was 8.4%. Studies generally reported clinically significant improvements in range of motion, Constant score and ASES score. Conclusion: aTSA in the rheumatoid patient results in improvements in range of motion and patient-reported outcomes. Rates of complications and survivorship are generally good in this population. However, it should be noted that there is significant heterogeneity in outcome reporting amongst the literature on this topic and that many studies fail to adequately report complication and revision rates. When compared to rTSA in patients with rheumatoid arthritis, evidence suggests that aTSA is still a viable treatment option despite the shift in utilization to rTSA.

Pharmacological Treatment in the Management of Glenohumeral Osteoarthritis.

Glenohumeral osteoarthritis (GH-OA) is a common cause of shoulder pain and is characterized by articular cartilage thinning, glenoid bone loss and deformity, osteophytosis, and other associated changes. The prevalence is estimated to be between 85 and 94% in men and women over the age of 80 years. A diagnosis of GH-OA is established based on clinical history, physical examination, and radiographic assessments. Non-pharmacological treatment options may serve as adjuvants to other therapies and should be incorporated for a more holistic approach to management. Pharmacological treatments include oral agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids and antidepressants. The National Institute for Health and Care Excellence (NICE) UK guidelines recommend NSAIDS as the first-line drugs for OA; topical forms of some of these agents can also be used. However, clinical evidence is largely lacking for its use in GH-OA, although patients with other types of OA, especially the knee and hip, are using these products in efforts to relieve joint pain. Intra-articular injections such as platelet-rich plasma, cortisone, and hyaluronic acid are usually used to control symptoms in moderate to advanced arthritis or in non-surgical candidates. Other non-surgical treatment options include suprascapular nerve block and radiofrequency ablation, and these options have been studied on different levels of evidence. Furthermore, all these treatments have their own indications, contraindications, and adverse effects profiles. Surgical treatment of GH-OA is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life.Level of Evidence IV, review article.

Revision Arthroscopic Bankart Repair for Anterior Shoulder Instability After a Failed Arthroscopic Soft-Tissue Repair Yields Comparable Failure Rates to Primary Bankart Repair: A Systematic Review.

BACKGROUND: The management of recurrent instability after arthroscopic Bankart repair remains challenging. Of the various treatment options, arthroscopic revision repairs are of increasing interest due to improved visualization of pathology and advancements in arthroscopic techniques and instrumentation. PURPOSE: We sought to assess the indications, techniques, outcomes, and complications for patients undergoing revision arthroscopic Bankart repair after a failed index arthroscopic soft-tissue stabilization for anterior shoulder instability. METHODS: We performed a systematic review of studies identified by a search of Medline, Embase, and PubMed. Our search range was from data inception to April 29, 2020. Outcomes include clinical outcomes and rates of complication and revision. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively. RESULTS: Twelve studies were identified, comprising 279 patients (281 shoulders) with a mean age of 26.1 ± 3.8 years and a mean follow-up of 55.7 ± 24.3 months. Patients had improvements in postoperative outcomes (eg, pain and function). The overall complication rate was 29.5%, the most common being recurrent instability (19.9%). CONCLUSION: With significant improvements postoperatively and comparable recurrent instability rates, there exists a potential role in the use of revision arthroscopic Bankart repair where the glenoid bone loss is less than 20%. Clinicians should consider patient history and imaging findings to determine whether a more rigorous stabilization procedure is warranted. Large prospective cohorts with long-term follow-up and improved documentation are required to determine more accurate failure rates.

The Effects of Blood Flow Restriction in Patients Undergoing Knee Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Blood flow restriction (BFR) training has been shown to have beneficial effects in reducing quadriceps muscle atrophy and improving strength in patients with various knee pathologies. Furthermore, the effectiveness of BFR training in patients undergoing knee surgery has been investigated to determine if its use can improve clinical outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to conduct a systematic review and meta-analysis to examine the effectiveness of BFR training in patients undergoing knee surgery. We hypothesized that BFR, before or after surgery, would improve clinical outcomes as well as muscle strength and volume. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: This systematic review and meta-analysis of peer-reviewed literature was conducted using PubMed, Embase, and Cochrane databases from 1980 to present. Search results were limited to those assessing BFR training in patients undergoing knee surgery published in a scientific peer-reviewed journal in English. Selected studies subsequently underwent data extraction, methodological quality assessment, and data analysis. RESULTS: Eleven studies were eligible, including anterior cruciate ligament reconstruction (n = 10) and knee arthroscopy (n = 1). Two studies specifically assessed BFR use in the preoperative time frame. For the meta-analysis, including 4 studies, the primary outcome variables included the cross-sectional area of the quadratus femoris muscle group assessed with magnetic resonance imaging or ultrasonography, and patient-reported outcome measure scores. The results demonstrated that BFR use in the postoperative time period can lead to a significant improvement in the cross-sectional area when quantifying muscle atrophy. However, there were no significant differences found for patient-reported outcome measures between the included studies. It should be noted that 4 of the included papers in this review reported increases in clinical strength when using BFR in the postoperative setting. Last, preoperative BFR training did not show any significant clinical benefit between the 2 studies. CONCLUSION: This is the first systematic review and meta-analysis to study the effects of BFR in patients undergoing knee surgery. The results of this analysis show that BFR in the postoperative period after knee surgery can improve quadriceps muscle bulk compared with a control group. However, future research should examine the effects of preconditioning with BFR before surgery. Lastly, BFR protocols need to be further investigated to determine which provide the best patient outcomes. This will help standardize this type of treatment modality for future studies.

The surgical management of distal triceps tendon ruptures: a systematic review.

BACKGROUND: Distal triceps tendon ruptures (DTTRs) are highly uncommon injuries and can be treated with surgical repair. The purpose of this review was to compare the outcomes and complications of various surgical techniques used for primary repair of DTTRs. METHODS: The electronic databases MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were searched from data inception to October 15, 2020. The Methodological Index for Non-randomized Studies tool was used to assess study quality. Data are presented descriptively. RESULTS: A total of 19 studies were identified, comprising 560 patients (565 triceps tendons), of whom 78.6% were male patients. The mean age was 46.1 ± 8.4 years, and the mean follow-up period was 31.8 ± 21.0 months. The overall complication rate across all DTTR repair procedures was 14.9%. The distribution of complications for each technique was 29.2% for the direct repair technique, 15.2% for the transosseous technique (transosseous suture), and 7.7% for the suture anchor technique. Common complications include ulnar neuropathies, infections, and pain. The overall rerupture rate for transosseous suture, suture anchor, and direct repair was 4.3% (n = 12), 2.1% (n = 3), and 0% (n = 0), respectively. Patients undergoing DTTR repair experience significant improvements postoperatively regarding pain, strength, and range of motion. CONCLUSIONS: Patients undergoing DTTR experience improvements in postoperative outcomes; however, there is a moderate reported risk of rerupture or complication. Owing to the heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another. Future studies should use large prospective cohorts and long-term follow-up to determine more accurate complication rates and outcome scores.