Reported Outcome Measures in Complex Fracture Elbow Dislocations: A Systematic Review.

BACKGROUND: Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison. METHODS: A systematic review was performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for non-randomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded. RESULTS: Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n=70), extension (n=62), pronation (n=68), or supination (n=67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (MEPS) (n=69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n=28 [34%]), the visual analog scale for pain (VAS) (n=27 [33%]), QuickDASH score (n=13 [15.7%]), and Oxford Elbow score (n=5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P=.313), study type (P=.689), complex fracture pattern (P=.211), or number of elbows included (P=.152). CONCLUSION: There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the MEPS and DASH outcomes measures as well as VAS pain rating scale in future studies to facilitate cross-study comparisons.

Insertion sites of latissimus dorsi tendon transfer performed during reverse shoulder arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Reverse shoulder arthroplasty (RSA) with concurrent latissimus dorsi transfer (LDT) is a potential treatment option for restoration of external rotation (ER). Biomechanical studies have emphasized the importance of the insertion site location for achieving optimal outcomes. In this systematic review and meta-analysis, we aimed to describe what insertion sites for LDT are utilized during concomitant RSA and their associated clinical outcomes. METHODS: A systematic review and meta-analysis were performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on patients who received RSA with LDT to restore ER and specified the site of tendon transfer insertion on the humerus. We first describe reported insertion sites in the literature. Secondarily, we present preoperative and postoperative range of motion and Constant score for different insertion sites as well as reported complications. RESULTS: Sixteen studies, analyzed as 19 separate cohorts (by insertion site and tendon-transfer), reporting on 264 RSAs with LDT (weighted mean age 66 years, follow-up 39 months, 61% female) were evaluated. Of these, 143 (54%) included a concomitant teres major transfer (LDT/TMT) and 121 (46%) were LDT-only. Fourteen cohorts (14/19, 74%) reported insertion at the posterolateral aspect of the greater tuberosity, four cohorts (4/19, 21%) reported insertion site at the lateral bicipital groove, and one cohort (1/19, 5%) reported separate LDT and TMT with insertion of the TMT to the posterolateral aspect of the greater tuberosity and LDT to the lateral bicipital groove. Meta-analysis revealed no differences in range of motion or Constant score based on humeral insertion site or whether the LDT was transferred alone or with TMT. Leading complications included dislocation, followed by infection and neuropraxia. No discernible correlation was observed between postoperative outcomes and the strategies employed for tendon transfer, prosthesis design, or subscapularis management. CONCLUSION: The posterolateral aspect of the greater tuberosity was the most-utilized insertion site for LDT performed with RSA. However, in the current clinical literature, LDT with or without concomitant TMT result in similar postoperative ROM and Constant score regardless of insertion site. Analysis of various proposed transfer sites reinforce the ability of LDT with RSA to restore both FE and ER in patients with preoperative active elevation and external rotation loss. Meta-analysis revealed significant improvements in range of motion and Constant score regardless of humeral insertion site or whether the LDT was transferred alone or with TMT, although future studies are needed to determine whether an ideal tendon transfer technique exists. LEVEL OF EVIDENCE: IV.

Can You Pay Your Way to Readership? Free to Publish Open Access Formats Receive Greater Readership and Citations Than Paid Open Access Formats in Total Knee Arthroplasty Literature.

BACKGROUND: As publishing with open access is becoming increasingly popular within orthopaedics, understanding the types of publishing options available and what each may deliver is critically important. Hybrid articles require a high article processing charge. Open journal articles have a lower fee, while closed license articles are freely accessible at no charge. Open repository articles are peer-reviewed manuscripts posted freely online. The purpose of this study was to determine the relationship between article type and resulting citations, social media attention, and readership in total knee arthroplasty (TKA) literature. METHODS: Open access TKA journal articles published since 2016 were found using the Altmetric Explorer Database. Data gathered included the Altmetric Attention Score (attention), Mendeley Readership Score (readership), and citations per article. Articles were grouped by type: open journal, hybrid, closed license, and open repository. Results were analyzed using descriptive statistics and Tukey's analysis; α = 0.05. RESULTS: A total of 9,606 publications were included. The open repository had the greatest mean citations (14.40), while open journal (9.55) had fewer than all other categories (P < .001). Hybrid had the greatest mean attention (10.35), and open journal (6.16) had a lower mean attention than all other categories (P ≤ .002). Open repository had the greatest mean readership (44.68), and open journal (34.00) had a lower mean readership than all other categories (P ≤ .012). The mean publication fee for paid publication options was $1,792 United States dollars. CONCLUSIONS: In open access TKA literature, free-to-publish open repositories had the greatest mean citations and readership. Free publication options, open repositories and closed licenses, had greater readership compared to paid publication options.

Influence of lateralized versus medialized reverse shoulder arthroplasty design on external and internal rotation: a systematic review and meta-analysis.

BACKGROUND: Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA. METHODS: We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model. RESULTS: Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°-44°] vs. 27° [22°-32°], P<0.001) and postoperative improvement in ER (20° [15°-26°] vs. 10° [5°-15°], P<0.001). Lateralized implants with subscapularis repair or medialized implants without subscapularis repair had significantly greater postoperative ER and postoperative improvement in ER compared to globally medialized implants with subscapularis repair (P<0.001 for both). Mean postoperative IR was reported in 56% (n=18) of studies and achieved the minimum necessary IR in 51% of lateralized (n=325, 5 cohorts) versus 36% (n=177, 5 cohorts) of medialized implants. CONCLUSIONS: Lateralized RSA produces superior axial rotation compared to medialized RSA. Lateralized RSA with subscapularis repair and medialized RSA without subscapularis repair provide greater axial rotation compared to medialized RSA with subscapularis repair. Level of evidence: 2A.

Publishing on Topical Subjects in Total Joint Arthroplasty Is Associated With Increased Social Media Attention.

BACKGROUND: Social media platforms are often used for research dissemination and collaboration. Given the increased prevalence of online-only publications, understanding what drives research dissemination is important. Here, we analyzed factors associated with increased social media attention among peer-reviewed publications in total knee arthroplasty, total hip arthroplasty, and unicompartmental knee arthroplasty. METHODS: We analyzed publications about total knee arthroplasty, total hip arthroplasty, or unicompartmental knee arthroplasty from 2010 to 2022 using a national database. We analyzed a weighted count of social media mentions, using negative binomial regressions adjusting for days since publication. Publications on "hot topics" in arthroplasty were examined including navigation/robotics, COVID-19, race/ethnicity, body mass index, and reimbursement. There were 9,542 publications included, 4,216 (44%) were open access (OA), 338 (3.5%) included navigation, 32 (0.34%) discussed race/ethnicity, 20 (0.2%) discussed COVID-19, 3,840 (40%) were randomized studies, 30 (0.3%) discussed reimbursement, and 2,867 (30%) were in top-10 orthopaedic journals. RESULTS: Factors associated with higher weighted score included studies about COVID-19 (50 versus 6.0, P < .001), race/ethnicity (15.8 versus 6.0, P < .001), OA status (6.3 versus 5.8, P = .001), and randomized studies (6.5 versus 5.7, P < .001). Studies from top-10 journals had a lower score (5.8 versus 6.2, P = .025), as did studies about body mass index (3.4 versus 6.1, P = .001). Studies about navigation and reimbursement did not have significantly different scores. CONCLUSIONS: Studies on COVID-19, race/ethnicity, randomized studies, and OA publication were associated with increased social media while those in top-10 orthopaedic journals had lower scores. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Relationship between the prosthesis scapular neck angle and clinical outcomes in reverse shoulder arthroplasty.

Background: Optimal glenosphere positioning in reverse shoulder arthroplasty (RSA) remains highly debated. We aimed to characterize the association between the prosthesis scapular neck angle (PSNA) and postoperative range of motion (ROM) and clinical outcome scores. Methods: A retrospective review of 284 RSAs using a single design with minimum 2-year follow-up was performed. Glenosphere tilt was measured postoperatively using PSNA. ROM and functional outcome scores were assessed preoperatively and at latest follow-up. The PSNA was dichotomized to inferior or superior groups (>90° vs ≤ 90°, respectively) and stratified into quartiles; ROM and outcome score measures were compared between groups controlling for inferior glenosphere overhang. Results: No range of PSNA was consistently associated with superior ROM, clinical outcome scores, or rates of complications including scapular notching. However, greater preoperative to postoperative improvement in active FE was found for superiorly (PSNA ≤ 90°) versus inferiorly tilted glenospheres (37° ± 33° vs 53° ± 35°, P = 0.005) and the greater improvement in active FE (57° ± 35°, P = 0.004) was further isolated to the first quartile (mean 85.1° ± 3.5°). Discussion: A lack of variation in clinical outcomes based on PSNA suggests negligible short-term (median follow-up 3.1 years) clinical significance when glenosphere tilt falls within the distribution of this cohort (mean 92.6° ± 6.2°).

The Obesity Paradox: A Nonlinear Relationship Between 30-Day Postoperative Complications and Body Mass Index After Total Shoulder Arthroplasty.

BACKGROUND: An inverse relationship coined the "obesity paradox" has been propositioned, in which body mass index (BMI) may be contradictorily protective in patients undergoing surgery or treatment of chronic disease. This study sought to investigate the BMI associated with the lowest rate of medical complications after total shoulder arthroplasty (TSA). METHODS: The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify adults who underwent elective primary TSA between January 2012 and December 2020. Thirty-day postoperative medical complications were extracted, which included death, readmission, pneumonia, pulmonary embolism, renal failure, and cardiac arrest, among others. BMI was classified into five categories (underweight [BMI <18.5 kg/m 2 ], normal weight [BMI ≥18.5 and <25 kg/m 2 ], overweight [BMI ≥25 and <30 kg/m 2 ], obese [BMI ≥30 and <40 kg/m 2 ], and morbidly obese [BMI ≥40 kg/m 2 ]). We examined the risk of any 30-day postoperative complications and BMI categorically and on a continuous basis using multivariable logistic regression controlling for age, sex, procedure year, and comorbidities. RESULTS: Of the 31,755 TSAs, 84% were White, 56% were female, and the average age of patients was 69.2 ± 9.3 years. Thirty-day postoperative medical complications occurred in 4.53% (n = 1,440). When assessed on a continuous basis, the lowest risk was in patients with a BMI between 30 and 35 kg/m 2 . Underweight individuals (BMI <18.5 kg/m 2 ) had the highest postoperative complication rates overall. The probability of medical complications increased with age and was greater for female patients. CONCLUSION: The relationship between BMI and complication risk in TSA is nonlinear. A BMI between 30 and 35 kg/m 2 was associated with the lowest risk of medical complications after TSA, and BMI<18.5 kg/m 2 had the highest risk overall, indicating some protective aspects of BMI against 30-day medical complications. Thus, obesity alone should not preclude patients from TSA eligibility, rather surgical candidacy should be evaluated in the context of patients' overall health and likelihood of benefit from TSA. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

The association between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to evaluate the relationship between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty (RSA) with stratification based on measurement method and implant design. METHODS: This systematic review was performed using PRISMA-P guidelines. PubMed/Medline, Cochrane Trials, and Embase were queried for articles evaluating the relationship between humeral lengthening and clinical outcomes inclusive of range of motion (ROM), strength, outcome scores, and pertinent complications (acromial and scapular spine fractures, nerve injury) after RSA. The relationship between humeral lengthening and clinical outcomes was reported descriptively overall and stratified by measurement method and implant design (globally medialized vs. lateralized). A positive association was defined as increased humeral lengthening being associated with greater ROM, outcome scores, or a greater incidence of complications, whereas a negative association denoted that increased humeral lengthening was associated with poorer ROM, outcome scores, or a lower incidence of complications. Meta-analysis was performed to compare humeral lengthening between patients with and without fractures of the acromion or scapular spine. RESULTS: Twenty-two studies were included. Humeral lengthening was assessed as the acromiohumeral distance (AHD), the distance from the acromion to the greater tuberosity (AGT), the acromion to the deltoid tuberosity (ADT), and the acromion to the distal humerus (ADH). Of 11 studies that assessed forward elevation, a positive association with humeral lengthening was found in 6, a negative association was found in 1, and 4 studies reported no association. Of studies assessing internal rotation (n = 9), external rotation (n = 7), and abduction (n = 4), all either identified a positive or lack of association with humeral lengthening. Studies assessing outcome scores (n = 11) found either a positive (n = 5) or no (n = 6) association with humeral lengthening. Of the studies that assessed fractures of the acromion and/or scapular spine (n = 6), 2 identified a positive association with humeral lengthening, 1 identified a negative association, and 3 identified no association. The single study that assessed the incidence of nerve injury identified a positive association with humeral lengthening. Meta-analysis was possible for AGT (n = 2) and AHD (n = 2); greater humeral lengthening was found in patients with fractures for studies using the AGT (mean difference 4.5 mm, 95% CI 0.7-8.3) but not the AHD. Limited study inclusion and heterogeneity prohibited identification of trends based on method of measuring humeral lengthening and implant design. CONCLUSION: The relationship between humeral lengthening and clinical outcomes after RSA remains unclear and requires future investigation using a standardized assessment method.

Quantifying success after anatomic total shoulder arthroplasty: the substantial clinically important percentage of maximal possible improvement.

BACKGROUND: Percentage maximal possible improvement (%MPI) has been described as a threshold by which to evaluate patient improvement after anatomic total shoulder arthroplasty (aTSA) that has favorable psychometric properties. The primary purpose of this study was to define the percentage maximal possible improvement (%MPI) thresholds associated with substantial clinical improvement following primary anatomic total shoulder arthroplasty (aTSA) and compare the rates of success as defined by those achieving the substantial clinical benefit (SCB) compared with the 30% MPI for different outcome scores. METHODS: A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary aTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to calculate improvement. Six outcome scores were assessed: the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), University of California-Los Angeles shoulder score (UCLA), Shoulder Pain and Disability Index (SPADI), and Shoulder Arthroplasty Smart (SAS) scores. The proportion of patients achieving the SCB and 30% MPI were determined for each outcome score. Thresholds for the substantial clinically important %MPI (SCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex. RESULTS: A total of 1593 shoulders with a mean follow-up of 59.3 months were included. Outcome scores with known ceiling effects (SST, ASES, UCLA) had higher rates of patients achieving the 30% MPI but not the previously reported SCB compared to scores without ceiling effects (Constant, SAS). The SCI-%MPI differed among outcome scores, and mean values were as follows: 48% for the SST, 39% for the Constant score, 53% for the ASES score, 55% for the UCLA score, 50% for the SPADI score, and 42% for the SAS score. The SCI-%MPI increased in patients older than 60 years (P ≤ .006 for all) and was greater in females for all scores assessed except the Constant score (P < .001 for all), meaning that patients with higher thresholds required a greater fraction of the maximum possible improvement for a given score to have substantial improvement. CONCLUSION: The %MPI judged relative to patient-reported substantial clinical improvement offers a new method to assess improvements across patient outcome scores. Given considerable variation in the %MPI corresponding to substantial clinical improvement, we recommend utilizing score-specific estimates of the SCI-%MPI to gauge success when evaluating patients undergoing primary aTSA.

Discordance between patient-reported and objectively measured internal rotation after reverse shoulder arthroplasty.

BACKGROUND: Patient satisfaction after reverse shoulder arthroplasty (RSA) partly relies on restoring functional internal rotation (IR). Although postoperative assessment of IR includes objective appraisal by the surgeon and subjective report from the patient, these evaluations may not vary together uniformly. We assessed the relationship between objective, surgeon-reported assessments of IR and subjective, patient-reported ability to perform IR-related activities of daily living (IRADLs). METHODS: Our institutional shoulder arthroplasty database was queried for patients undergoing primary RSA with a medialized-glenoid lateralized-humerus design between 2007-2019 and minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, and tumor were excluded. Objective IR was measured to the highest vertebral level reached with the thumb. Subjective IR was reported based on patients' rating (normal, slightly difficult, very difficult, or unable) of their ability to perform 4 IRADLs (tuck in shirt with hand behind back, wash back or fasten bra, personal hygiene, and remove object from back pocket). Objective IR was assessed preoperatively and at latest follow-up and reported as median and interquartile ranges. RESULTS: A total of 443 patients were included (52% female) at a mean follow-up of 4.4 ± 2.3 years. Objective IR improved pre- to postoperatively from L4-L5 (buttocks to L1-L3) to L1-L3 (L4-L5 to T8-T12) (P < .001). Preoperatively reported IRADLs of "very difficult" or "unable" significantly decreased postoperatively for all IRADLs (P ≤ .004) except those unable to perform personal hygiene (3.2% vs. 1.8%, P > .99). The proportions of patients who improved, maintained, and lost objective and subjective IR was similar between IRADLs; 14%-20% improved objective IR but lost or maintained subjective IR and 19%-21% lost or maintained the same objective IR but improved subjective IR depending on the specific IRADL assessed. When ability to perform IRADLs improved postoperatively, objective IR also increased (P < .001). In contrast, when subjective IRADLs worsened postoperatively, objective IR did not significantly worsen for 2 of 4 IRADLs assessed. When examining patients who reported no change in ability to perform IRADLs pre- vs. postoperatively, statistically significant increases in objective IR were found for 3 of 4 IRADLs assessed. CONCLUSIONS: Objective improvement in IR parallels improvements in subjective functional gains uniformly. However, in patients with worse or equivalent IR, the ability to perform IRADLs postoperatively does not uniformly correlate with objective IR. When attempting to elucidate how surgeons can ensure patients will have sufficient IR after RSA, future investigations may need to use patient-reported ability to perform IRADLs as the primary outcome measure rather than objective measures of IR.

Thoracic outlet syndrome: a review.

Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.