Defining recovery trajectories after shoulder arthroplasty: a latent class analysis of patient-reported outcomes.

BACKGROUND: Patients undergoing total shoulder arthroplasty (TSA) can have varying levels of improvement after surgery. As patients typically demonstrate a nonlinear recovery trajectory, advanced analysis investigating the degrees of variation in outcomes is needed. Latent class analysis (LCA) is a mixed and multilevel model that estimates random slope variance to evaluate heterogeneity in outcome patterns among patient subgroups and can be used to outline differing recovery trajectories. The purpose of this study was to determine recovery trajectory patterns after TSA and to identify factors that predict a given trajectory. METHODS: Data from a prospectively collected single institutional database of patients undergoing anatomic and reverse TSA were utilized. Patients were included if they had American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores preoperatively, as well as postoperative scores at 6 weeks, 6 months, 1 year, and 2 years. Patients were excluded if they underwent a revision procedure or hemiarthroplasty or had prior infection. LCA was used to subdivide the patient cohort into subclasses based on postoperative recovery trajectory. This was performed for all patients as well as anatomic TSA and reverse TSA as separate groups. Unpaired Student t tests, analysis of variance, and Fisher exact test were used to compare classes based on factors including age, body mass index, sex, preoperative diagnosis, and type of arthroplasty. RESULTS: A total of 244 TSAs were included in the final analysis, comprising 89 anatomic TSA and 155 reverse TSA. In the combined group, LCA modeling revealed 3 patterns for recovery: Resistant Responders had low baseline scores (ASES < 30) and poor final results (ASES < 50), Steady Progressors had moderate baseline scores (ASES 30-50) with moderate final results (ASES 50-75), and High Performers had moderate baseline scores (ASES > 50) with excellent final results (ASES > 75). For anatomic TSA, we identified Delayed Responders with moderate baseline scores and a delayed response before ultimately achieving moderate final results, Steady Progressors with moderate baseline scores and a steady progression to achieve moderate final results, and High Performers who had moderate baseline scores and excellent final results. For reverse TSA, we identified Late Regressors with low baseline scores and poor final results, Steady Progressors with moderate baseline scores and moderate final results, and High Performers with moderate baseline scores and excellent final results. CONCLUSIONS: Patients recover in a heterogenous manner following TSA. Through LCA, we identified different recovery trajectories for patients undergoing anatomic TSA and reverse TSA.

Outpatient Shoulder Arthroplasty-A Systematic Review.

OBJECTIVE: Recent reports have shown that outpatient shoulder arthroplasty (SA) may be a safe alternative to inpatient management in appropriately selected patients. The purpose was to review the literature reporting on outpatient SA. METHODS: A systematic review of publications on outpatient SA was performed. Included publications discussed patients who were discharged on the same calendar day or within 23 hours from surgery. Articles were categorized by discussions on complications, readmissions, and safety, patient selection, pain management strategies, cost effectiveness, and patient and surgeon satisfaction. RESULTS: Twenty-six articles were included. Patients undergoing outpatient SA were younger and with a lower BMI than those undergoing inpatient SA. Larger database studies reported more medical complications for patients undergoing inpatient compared to outpatient SA. Articles on pain management strategies discussed both single shot and continuous interscalene blocks with similar outcomes. Both patients and surgeons reported high levels of satisfaction following outpatient SA, and cost analysis studies demonstrated significant cost savings for outpatient SA. CONCLUSION: In appropriately selected patients, outpatient SA can be a safe, cost-saving alternative to inpatient care and may lead to high satisfaction of both patients and physicians, though further studies are needed to clarify appropriate utilization of outpatient SA.

Altered tibiofemoral position following ACL reconstruction is associated with cartilage matrix changes: A voxel-based relaxometry analysis.

The purpose of this study was to analyze the relationship between postsurgical tibial translation (TT) and tibial rotation (TR) with cartilage matrix changes using quantitative magnetic resonance imaging, specifically voxel-based relaxometry with T1ρ and T2 mapping sequences. Knee magnetic resonance imaging's (MRI's) of 51 patients with unilateral anterior cruciate ligament injury, no concomitant ligamentous injury, history of osteoarthritis (OA), and previous knee surgery were scanned prior to surgery. Thirty-four patients completed follow-up MRI scans at 6-month, 1- and 2-year post-reconstruction and were included in this study. Knee biomechanics, T1ρ, and T2 were calculated using an in-house Matlab program. Compared to the contralateral knee, the injured knee demonstrated significantly increased anterior TT at baseline (P < .001), 6-month (P < .001), 1- (P = .001), and 2-year (P < .001). Furthermore, patients were divided into groups based on TT at 6-month. When compared to patients with normal TT, those with increased anterior TT at 6-month displayed significantly longer T1ρ and T2 relaxation times in 10.4% and 7.4% of the voxels in the injured medial tibia at 1-year, respectively, as well as 12.4% and 9.8% of the voxels in the injured medial tibia at 2-year, respectively. Our results demonstrate an association between abnormal tibiofemoral position and early degradative changes to the articular cartilage matrix of the injured knee. Clinical significance: These findings suggest that altered tibiofemoral position following ACL reconstruction is associated with early degeneration of knee cartilage. Future prospective studies employing longer follow-up times are warranted to evaluate the relationship between abnormal tibiofemoral position and the early onset of posttraumatic OA.