Modular Baseplate Augmentation: A Simple and Effective Method for Addressing Eccentric Glenoid Wear.

BACKGROUND: Augmented baseplates can be effective at addressing eccentric glenoid wear in reverse total shoulder arthroplasty (rTSA). However, these implants often come in a limited number of predetermined shapes that require additional reaming to ensure adequate glenoid seating. This typically involves complex instrumentation and can have a negative impact on implant stability. Modular baseplate augmentation based on intra-operative measurements may allow for more precise defect filling while preserving glenoid bone. The purpose of this investigation was to assess the stability of a novel ringed baseplate with modular augmentation in comparison to non-augmented standard and ringed baseplate designs. METHODS: In this biomechanical study, baseplate micromotion was tested for three constructs according to American Society for Testing and Materials (ASTM) guidelines. The constructs included a non-augmented curved baseplate, a non-augmented ringed baseplate and ringed baseplate with an 8 mm locking modular augmentation peg. The non-augmented constructs were mounted flush onto polyurethane (PU) foam blocks, while the augmented baseplate was mounted on a PU block with a simulated defect. Baseplate displacement was measured prior to and after 100,000 cycles of cyclic loading. RESULTS: Prior to cyclic loading, the non-augmented and augmented ringed baseplates both demonstrated significantly less micromotion than the non-augmented curved baseplate design (81.1 µm vs 97.2 µm vs 152.7 µm; p=0.009). After cyclic loading, both ringed constructs continued to have significantly less micromotion compared to the curved design (105.5 µm vs 103.2 µm vs 136.6 µm; p<0.001). The micromotion for both ringed constructs remained below the minimum threshold required for bony ingrowth (150 µm) at all time points. CONCLUSION: In the setting of a simulated glenoid defect, locked modular augmentation of a ringed baseplate does not result in increased baseplate micromotion when compared to full contact, non-augmented baseplates. This design offers a simple method for tailored baseplate augmentation that can match specific variations in glenoid anatomy, limiting the need for excessive reaming and ultimately optimizing the environment for long term implant stability. LEVEL OF EVIDENCE: Basic Science Study; Biomechanics.

Tensionable lesser tuberosity osteotomy repair for anatomic total shoulder arthroplasty.

A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review.

While several proximal humerus fractures treated nonsurgically reach satisfactory outcomes, some become symptomatic malunions or nonunions with pain and dysfunction. When joint-preserving options such as malunion or nonunion repair are not optimal because of poor remaining bone stock or glenohumeral arthritis, shoulder arthroplasty is a good option. Because of the semiconstrained design of reverse shoulder arthroplasty, it is effective at improving function when there is notable bony deformity or a torn rotator cuff. Clinical studies have demonstrated reliable outcomes, and a classification system exists that is helpful for predicting prognosis and complications. By understanding the associated pearls and pitfalls and with careful management of the tuberosities, reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae.

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Effect of vitamin E-enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene.

BACKGROUND: Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component's mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E-enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E-enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component. METHODS: Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated. RESULTS: The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05). CONCLUSIONS: A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E-enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.

Surprise Billing in Elective Shoulder Surgery and Its Effect on Patient Satisfaction.

Patients often receive multiple bills following surgery, which may come as a surprise to them if they are not appropriately informed or educated prior to surgery. The purpose of this study was to identify whether surprise billing occurs following shoulder rotator cuff repair and its effect on patient satisfaction. The study surveyed adult patients who underwent elective rotator cuff repair from January 2020 to October 2021. Patients were asked if they received unexpected bills after their surgery, as well as about details regarding those bills. Additionally, patients were asked about their medical insurance carrier, knowledge of the billing process prior to surgery, and how they felt the process could be improved. Finally, patients were asked how these bills and the overall billing process affected their surgical satisfaction. Of the 158 responses, 25% of the patients stated they received at least one surprise bill following their rotator cuff surgery, with 57% of these bills being greater than $1000. Patients who received surprise bills reported being significantly less satisfied with their surgery (P<.001) and felt their billing experience affected their surgical satisfaction (64% vs 9%, P<.001). One in 4 patients undergoing elective rotator cuff repair received a surprise bill following surgery. These bills were monetarily substantial and significantly affected surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(2):123-127.].

Elliptical Humeral Head Implants in Anatomic Total Shoulder Arthroplasty.

Humeral implants for anatomic total shoulder arthroplasty and hemiarthroplasty have typically used spherical humeral heads that have a uniform diameter and radius of curvature. However, the native humeral head has a more elliptical morphology, which has spurred interest in nonspherical implant designs. Cadaveric studies indicate that the native humeral head diameter is 10% longer in the superior-inferior plane than the anterior-posterior plane and has a radius of curvature that is approximately 8% greater. An elliptical implant that more closely replicates native anatomy may allow for more accurate coverage of the humeral resection surface with less implant overhang and risk of overstuffing. Biomechanical evidence suggests that an elliptical implant yields glenohumeral kinematics that mimic the native joint, and early clinical results are promising. As clinical research continues to emerge, it will become clearer whether encouraging cadaveric, biomechanical, and early clinical data translates to meaningful sustained improvements in patient outcomes.

The Incidence of Symptomatic Mediastinal Compromise Following Medial Clavicle Fractures.

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [Orthopedics. 2023;46(3):e161-e166.].

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

BACKGROUND: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. METHODS: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. RESULTS: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006). CONCLUSION: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Return to driving following anatomic and reverse shoulder arthroplasty: a comparative analysis.

BACKGROUND: The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA). METHODS: All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery). RESULTS: Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively. CONCLUSION: Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

Malpractice against shoulder surgeons: what the data say.

BACKGROUND: Thousands of orthopedic surgeons in the United State face medical malpractice claims annually; however, little is known regarding the common causes for litigation against shoulder surgeons. In addition, the current analysis does not take into consideration how surgical frequency affects the litigation likelihood. The purpose of our investigation was to identify the most common causes of litigation against shoulder surgeons in the United States adjusting for surgical frequency. METHODS: The VerdictSearch database was used using the search terms "medical malpractice," "shoulder," and "NOT cancer." Results were queried, and all studies pertaining to orthopedic shoulder surgery included. Data gathered included cause of lawsuit, indemnity paid, type of surgery performed, results of the cases, verdict or settlement, and, if applicable, technical error. A query of a multisurgeon institutional database was conducted to determine how frequently surgeries were performed. Then the frequency of litigation was adjusted by the procedure frequency to determine which surgery has the greatest likelihood to be litigated relative to rotator cuff surgery. RESULTS: Forty-five cases were included in our study. After adjusting for the procedure frequency, the most likely procedure to be litigated, relative to rotator cuff repair, was manipulation under anesthesia (MUA), 251 times more likely to be litigated, and washout/lavage procedures, 17 times more likely to be litigated. Injection and total shoulder arthroplasty were 23 and 14 times less likely to be litigated relative to rotator cuff repair, respectively. In addition, the average age of the patients was 47 years, and 53% of the cases involved a male plaintiff. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement. CONCLUSIONS: This study identifies that MUA and lavage/washout procedures are much more likely to be litigated relative to rotator cuff repair. Rotator cuff repair is actually one of the least likely procedures to be litigated. Furthermore, settlement may represent a method of decreasing the indemnity paid for malpractice cases for which surgeons are implicated.

Biomechanical comparison of elbow stability constructs.

BACKGROUND: Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. METHODS: Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. RESULTS: Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. CONCLUSION: The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

The Opioid Risk Tool: Can This Validated Tool Predict Post-Operative Opioid Dependence Following Arthroscopic Rotator Cuff Repair?

Background: Numerous attempts have been made to decrease the incidence of opioid dependence after orthopedic surgeries. However, no effective means of preoperative risk stratification currently exists. The purpose of this study was to determine the ability of the Opioid Risk Tool (ORT) to predict the rate of opioid dependence 2 years after arthroscopic rotator cuff repair (ARCR). Methods: We prospectively evaluated all patients undergoing primary ARCR at a single institution over a 1.5 year period with a minimum of 2-year follow-up. All patients completed the ORT prior to surgery and were stratified into Low, Moderate, and High risk categories. The primary outcome was postoperative opioid dependence, defined as receiving a minimum of 6 opioid prescriptions within 2 years following surgery. Secondary outcomes included the total number of morphine milligram equivalents prescribed, total number of opioid prescriptions filled, and total number of opioid pills prescribed during this time interval. All outcome variables were compared amongst Low, Moderate, and High risk groups. Assessment of a statistical correlation between each outcome variable and individual numerical ORT scores (1-9) was performed. Results: A total of 137 patients were included for analysis. No statistically significant difference was noted in any primary or secondary outcome variable when compared between Low, Moderate, and High risk groups. The total cohort demonstrated a 19% rate of post-operative opioid dependence. No correlation was identified between any outcome variable and individual numerical ORT scores. A greater rate of dependence and quantity of opioids prescribed was noted amongst patients with a history of prior opioid use. Conclusion: The ORT was not predictive of the risk of opioid dependence or quantity of opioids prescribed after ARCR. Attention should be focused on alternative means of identification and management of patients at risk for opioid dependence after orthopedic procedures, including those with a history of prior opioid use.

Midterm outcomes and survivorship of arthroscopic elbow debridement: a comparison of posttraumatic versus primary degenerative osteoarthritis.

BACKGROUND: Arthroscopic debridement is an effective means of surgical management of both degenerative osteoarthritis (DOA) and posttraumatic arthritis (PTA) of the elbow. However, the difference in the efficacy and longevity of this procedure when performed for these two distinct pathologies remains in question. The purpose of this study was to identify and compare the midterm outcomes and survivorship of arthroscopic debridement of elbow PTA and DOA. METHODS: A retrospective analysis of patients undergoing arthroscopic debridement of DOA and PTA of the elbow was performed. A questionnaire containing the Oxford Elbow Score, as well as questions regarding the incidence of reoperation, additional nonoperative intervention, complications, pain, and satisfaction, was given at 5 years, minimum, after surgery. The midterm survivorship of arthroscopic debridement free of reoperation for any reason, as well as the remaining outcome measurements obtained via the questionnaire and in-office evaluation, was compared between PTA and DOA cohorts. RESULTS: Eighty patients (DOA = 36, PTA = 44) were included in this study for analysis. All 36 patients with DOA were noted to be male. Follow-up time at the date of questionnaire response was 7.9 years (range, 5.6-11.8) in the DOA cohort and 8.6 years (range, 5.7-12.7) in the PTA cohort. Reoperation rates of 5.6% and 11.4% were identified in the DOA and PTA cohorts, respectively. No statistical difference was noted in reoperation rate, survivorship, or any measured patient-reported outcomes between cohorts at the final follow-up visit. Both cohorts demonstrated a significant improvement in Visual Analog Scale pain scores (P < .001) and ROM. Postoperative ROM was obtained at the final clinic visit at an average follow-up duration of 151 days and 255 days in the DOA and PTA cohorts, respectively. However, no difference in the degree of improvement in either outcome variable was identified after a comparison between cohorts. CONCLUSION: Arthroscopic debridement is an equally efficacious treatment option for DOA and PTA of the elbow. Patients with either pathology can expect satisfactory elbow function and an improvement in pain with little chance of reoperation at the midterm of the follow-up duration.

Reliable Pain Relief But Variable Return to Play After Arthroscopic Elbow Debridement in Baseball Players.

PURPOSE: We sought to determine the rate of return to play (RTP) in baseball players following arthroscopic elbow debridement for the management of the symptomatic elbow. METHODS: A retrospective case series with prospectively collected data via questionnaire was conducted on all baseball players who underwent an arthroscopic elbow debridement, from July, 15, 2004 to November 1, 2017. A postoperative questionnaire was released at an average 7.25 year follow-up. Data collected included age, gender, laterality, preoperative diagnosis, range of motion, duration and characterization of symptoms, visual analog scale (VAS) pain score, complications, level of play, and RTP. RESULTS: Follow-up data were available on 18 baseball players. Average age was 19.7 years (range 16-24). Seventeen were pitchers, and 1 was a catcher. Level of play included 12 collegiate athletes, 2 high school athletes, 2 recreational athletes, 1 minor league athletes, and 1 major league athlete. Rate of RTP was 61% (11/18) with 6 returning to a greater level and 5 to an equal level. The length of time to RTP following surgery was most commonly within 6-8 months (44.4%, 8/18). Mean VAS pain score improved from 6.9 to 0.75 (P = <.001). 27.8% (5/18) had repeat surgery secondary to recurrent/persistent stiffness or heterotopic ossification. 77.8% (14/18) of patients rated their final outcome as either "very satisfied" (9/18), or "satisfied" (5/18). CONCLUSIONS: Pain can reliably be relieved following arthroscopic elbow debridement in baseball players. Although patient satisfaction may be high, patients do not always return to their previous level of play. Patients must be counseled on the risk of limited postoperative athletic capacity before the time of surgery. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Effect of State Legislation on Opioid Prescriptions Following Arthroscopic Rotator Cuff Repair.

New Jersey State Law, P.L. 2017 Chapter 28 22, C.24:21-15.2, passed in February 2017, is the most restrictive opioid legislation passed thus far in the United States. This study evaluated the effects of this legislation on the postoperative opioid prescriptions of patients undergoing arthroscopic rotator cuff repair (RCR). Opioid prescriptions were compared following arthroscopic RCR before and after implementation of the new law using the New Jersey Prescription Monitoring Program Aware Drug Database. A consecutive cohort of patients who underwent RCR during a 6-month period prior to the legislation was compared with a consecutive cohort of patients who underwent RCR during a 6-month period after the law went into effect. The primary outcome measure was prescribed postoperative milligram morphine equivalents (MME) and number of pills prescribed. There were 265 patients in the pre-law cohort and 198 patients in the post-law cohort. In the pre-law cohort, there was a median of 1250 MME (interquartile range [IQR], 900-1800 MME) and a median of 100 pills (IQR, 60-175 pills) prescribed postoperatively. In the post-law cohort, a median of 900 MME (IQR, 550-1050 MME) and a median of 60 pills (IQR, 60-90 pills) were prescribed postoperatively. A comparison of pre-law and post-law data for MME and number of pills prescribed was statistically significant (P<.001). The median opioid consumption MME and number of pills prescribed following RCR decreased significantly following the implementation of the New Jersey state law. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following RCR. [Orthopedics. 2021;44(1):e80-e84.].

Improvements in sexual function following arthroscopic rotator cuff repair.

BACKGROUND: Three-fourths of Americans are sexually active, and studies show a correlation between sexual activity and good health. Rotator cuff tears and subsequent repairs can cause significant disruption in daily living including sexual activity. Orthopedic surgeons rarely discuss sexual activity with patients. Therefore, patients have little information about expectations, restrictions, and return to sexual activity. The primary goal of this study was to evaluate patient improvement in sexual activity following arthroscopic rotator cuff repair and evaluate factors that affect sexual activity. METHODS: An anonymous 20-item multiple-choice survey was sent to patients > 6 months after arthroscopic rotator cuff repair performed by 7 fellowship-trained orthopedic shoulder and elbow surgeons between March 2018 and May 2019. The survey assessed preoperative and postoperative sexual activity and included questions regarding frequency, pain, positioning, and postoperative injury. RESULTS: A total of 88 patients met the inclusion criteria and completed the survey. Preoperatively, 65% of patients admitted that their shoulder interfered with the quality and/or frequency of their sexual activity, most commonly secondary to an inability to bear weight on the affected arm (31%). Postoperatively, the majority of patients (79%) found it easier to engage in sexual activity, with 35% of patients attributing this to less pain. At 6 weeks postoperatively, 72% of patients returned to sexual activity. The overall trend demonstrated a statistically significant (P < .001) increase in sexual activity frequency as one progressed from his or her operative date. It is interesting to note that 31% of patients removed their sling to engage in sexual activity after surgery, with 7% admitting to aggravating their shoulder or causing significant pain. CONCLUSION: Prior to arthroscopic rotator cuff repair, most patients experience limitations in the quality and/or frequency of their sexual activity secondary to their shoulder. Following surgery, the majority of patients will more easily engage in sexual activity by 6 weeks, with increasing frequency as time progresses from surgery. Many patients are noncompliant with sling wear during sexual activity, and 7% will aggravate their shoulder.

Opioid-Free Arthroscopic Rotator Cuff Repair.

Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions.

BACKGROUND: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. METHODS: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. RESULTS: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. CONCLUSION: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.