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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.
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Since the advent of Neer's total shoulder arthroplasty in 1974, glenoid implant design has evolved to optimize patient function and increase implant longevity. Glenoid loosening continues to be a major cause of total shoulder arthroplasty failure due to both patient and implant factors. The more recent development of posterior augmented glenoids, peg fixation with ingrowth potential, inlay implants, zoned conformity implants, and convertible glenoids have all shown promising results in improving glenoid fixation and survival in different clinical circumstances. The increased utilization of 3D CT scans, preoperative planning, and patient-specific instrumentation has paralleled innovation in glenoid implants with the aim of improving the accuracy of glenoid implant placement to further optimize patient function and implant longevity. Specific indications for the variety of glenoid implants available today are still being studied. The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual.
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INTRODUCTION: The Walch classification has been widely accepted and further developed as a method to characterize glenohumeral arthritis. However, many studies have reported low and inconsistent measures of the reliability of the Walch classification. The purpose of this study was to review the literature on the reliability of the Walch classification and characterize how imaging modality and classification modifications affect reliability. METHODS: A systematic review of publications that included reliability of the Walch classification reported through intraobserver and interobserver kappa values was conducted. A search in January 2021 and repeated in July 2023 used the terms ["Imaging" OR "radiography" OR "CT" OR "MRI"] AND ["Walch classification"] AND ["Glenoid arthritis" OR "Shoulder arthritis"]. All clinical studies from database inception to July 2023 that evaluated the Walch or modified Walch classification's intraobserver and/or interobserver reliability were included. Cadaveric studies and studies that involved subjects with previous arthroplasty, shoulder débridement, glenoid reaming, interposition arthroplasty, and latarjet or bankart procedure were excluded. Articles were categorized by imaging modality and classification modification. RESULTS: Thirteen articles met all inclusion criteria. Three involved the evaluation of plain radiographs, 10 used CT, two used three-dimensional (3D) CT, and four used magnetic resonance imaging. Nine studies involved the original Walch classification system, five involved a simplified version, and four involved the modified Walch. Six studies examined the reliability of raters of varying experience levels with none reporting consistent differences based on experience. Overall intraobserver reliability of the Walch classifications ranged from 0.34 to 0.92, and interobserver reliability ranged from 0.132 to 0.703. No consistent trends were observed in the effect of the imaging modalities or classification modifications on reliability. DISCUSSION: The reliability of the Walch classification remains inconsistent, despite modification and imaging advances. Consideration of the limitations of the classification system is important when using it for treatment or prognostic purposes.
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Artritis , Imagen por Resonancia Magnética , Articulación del Hombro , Humanos , Reproducibilidad de los Resultados , Articulación del Hombro/diagnóstico por imagen , Artritis/clasificación , Artritis/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Variaciones Dependientes del Observador , Imagenología TridimensionalRESUMEN
BACKGROUND: Prior research has shown that industry funding can impact the outcomes reported in medical literature. Limited data exist on the degree of bias that industry funding may have on shoulder arthroplasty literature outside of the Journal of Shoulder and Elbow Surgery. The purpose of this study is to characterize the type and frequency of funding for recently published shoulder arthroplasty studies and the impact of industry funding on reported outcomes. We hypothesized that studies with industry funding are more likely to report positive outcomes than those without. MATERIALS AND METHODS: We performed a retrospective study searching all articles with the term "shoulder arthroplasty," "reverse shoulder arthroplasty," "anatomic total shoulder arthroplasty," or "total shoulder arthroplasty" on PubMed from the years January 2020 to December 2022. The primary outcome of studies was coded as either positive, negative, or neutral. A positive result was defined as one in which the null hypothesis was rejected. A negative result was defined as one in which the result did not favor the group in which the industry-funded implant was used. A neutral result was defined as one in which the null hypothesis was confirmed. Article funding type, subcategorized as National Institutes of Health funding or industry funding was recorded. Author disclosures were recorded to determine conflicts of interest. Statistical analysis was conducted using the χ2 test and Fisher exact test. RESULTS: A total of 750 articles reported on either conflict of interest or funding source and were included in the study. Of the total number of industry-funded studies, the majority were found to have a positive primary endpoint (58.1%, 104 of 179), as compared to a negative (7.8%, 14 of 179) or neutral endpoint (33.5%, 60 of 179) (P = .004). Overall, 363 articles reported an author conflict of interest, and the majority of these studies had positive primary endpoint (55.6%, 202 of 363) as compared to negative (9.1%, 33 of 363) or neutral endpoints (34.4%, 125 of 363) (P = .002). CONCLUSION: The results of this study suggest that there is a significant relationship between conflicts of interest and the primary outcome of shoulder arthroplasty studies, beyond the overall positive publication bias. Studies with industry funding and author conflicts of interest both report positive outcomes more frequently than negative outcomes. Shoulder surgeons should be aware of this potential bias when choosing to base clinical practice on published data.
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Artroplastía de Reemplazo de Hombro , Humanos , Artroplastía de Reemplazo de Hombro/economía , Estudios Retrospectivos , Investigación Biomédica/economía , Conflicto de Intereses , Apoyo a la Investigación como AsuntoRESUMEN
Background: The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model. Methods: To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques. Results: No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16). Discussion: In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.
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BACKGROUND: Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time. METHODS: The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members. RESULTS: The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P = .05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P < .001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P = .50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P < .001) and total hip arthroplasty (12.6% vs. 34.7%, P < .001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P = .017). DISCUSSION AND CONCLUSION: A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics-and to mentor female residents and medical students interested in shoulder surgery-may bring real change to the gender differences among shoulder replacement surgeons over the coming years.
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Artroplastía de Reemplazo de Hombro , Cirujanos Ortopédicos , Humanos , Femenino , Masculino , Artroplastía de Reemplazo de Hombro/tendencias , Artroplastía de Reemplazo de Hombro/estadística & datos numéricos , Estados Unidos , Cirujanos Ortopédicos/estadística & datos numéricos , Cirujanos Ortopédicos/tendencias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Factores Sexuales , Medicare , Médicos Mujeres/estadística & datos numéricos , Médicos Mujeres/tendenciasRESUMEN
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.
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Artroplastía de Reemplazo de Hombro , Ensayo de Materiales , Polietilenos , Diseño de Prótesis , Falla de Prótesis , Prótesis de Hombro , Vitamina E , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Fenómenos Biomecánicos , Tamaño de la Partícula , Osteólisis/etiología , Osteólisis/prevención & control , Articulación del Hombro/cirugíaRESUMEN
BACKGROUND: Subscapularis function is critical after anatomic total shoulder arthroplasty (aTSA). Recently, however, a technique has been described that features a chevron or V-shaped subscapularis tendon cut (VT). This biomechanical study compared repair of the standard tenotomy (ST), made perpendicular to the subscapularis fibers, to repair of the novel VT using cyclic displacement, creep, construct stiffness, and load to failure. METHODS: This biomechanical study used 6 pairs of fresh frozen paired cadaveric shoulder specimens. One specimen per each pair underwent VT, the other ST. Subscapularis tenotomy was performed 1 cm from the insertion onto the lesser tuberosity. For VT, the apex of the V was 3 cm from the lesser tuberosity. After tenotomy, each humerus underwent humeral head arthroplasty. Eight figure-of-8 sutures were used to repair the tenotomy (Ethibond Excel; Ethicon, US LLC). Specimens were cyclically loaded from 2 to 100 N at 45 degrees abduction at a rate of 1 Hz for 3000 cycles. Cyclic displacement, creep, and stiffness and load to failure were measured. RESULTS: Cyclic displacement did not differ significantly between the ST and VT from 1 to 3000 cycles. The difference in displacement between the V-shaped and standard tenotomy at 3000 cycles was 1.57 mm (3.66 ± 1.55 mm vs. 5.1 ± 2.8 mm, P = .31, respectively). At no point was the V-shape tenotomy (VT) >3 mm of average displacement, whereas the standard tenotomy (ST) averaged 3 mm of displacement after 3 cycles. Creep was significantly lower for VT in cycles 1 through 3. For all cycles, stiffness was not significantly different in the VT group compared with the ST group. Load to failure was not statistically significant in the VT compared to the standard tenotomy throughout all cycles (253.2 ± 27.7 N vs. 213.3 ± 76.04 N; P = .25, respectively). The range of load to failure varied from 100 to 301 N for standard tenotomy compared with 216 to 308 N for VT. CONCLUSION: This study showed that VT and ST demonstrated equivalent stiffness, displacement, and load to failure. VT had the benefit of less creep throughout the first 3 cycles, although there was no difference from cycle 4 to 3000. The VT had equivalent biomechanical properties to the ST at time zero, an important first step in our understanding of the technique. The VT technique warrants further clinical study to determine if the technique has clinical benefits over ST following aTSA.
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Manguito de los Rotadores , Articulación del Hombro , Humanos , Manguito de los Rotadores/cirugía , Articulación del Hombro/cirugía , Tenotomía/métodos , Fenómenos Biomecánicos , Osteotomía/métodos , Cabeza Humeral , CadáverRESUMEN
BACKGROUND: Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. METHODS: This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. RESULTS: A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. CONCLUSION: In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.
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Tendón Calcáneo , Lesiones del Manguito de los Rotadores , Músculos Superficiales de la Espalda , Humanos , Masculino , Persona de Mediana Edad , Femenino , Tendón Calcáneo/trasplante , Resultado del Tratamiento , Músculos Superficiales de la Espalda/cirugía , Transferencia Tendinosa/métodos , Estudios Retrospectivos , Rango del Movimiento Articular , Aloinjertos , Dolor/etiología , Artroscopía/métodosRESUMEN
BACKGROUND: Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services. METHODS: A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes. RESULTS: A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P = .0328) and 90 days (OR 1.215; P = .0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P < .001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P < .001). CONCLUSION: Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation.
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Artroplastía de Reemplazo de Hombro , Costos de la Atención en Salud , Servicios de Atención de Salud a Domicilio , Readmisión del Paciente , Complicaciones Posoperatorias , Puntaje de Propensión , Humanos , Masculino , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/economía , Femenino , Servicios de Atención de Salud a Domicilio/economía , Artroplastía de Reemplazo de Hombro/economía , Estudios Retrospectivos , Anciano , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Persona de Mediana EdadRESUMEN
Introduction: Patients on chronic corticosteroids/immunosuppressants (SI) undergoing orthopaedic surgery are at an increased risk for surgical complications and worse outcomes. However, whether or not chronic preoperative SI use increases the risk for 30-day complications in patients undergoing primary total shoulder arthroplasty (SA) has yet to be explored. Methods: From 2006 to 2019, the National Surgical Quality Improvement Program (NSQIP) database was used to identify all patients who underwent primary SA (anatomic TSA and reverse TSA). Patients were stratified into two cohorts: chronic preoperative SI users and those without use. Bivariate and multivariate analyses were utilized in this study. Results: Of the 26,979 patients who underwent primary SA, 25,656 (95.1%) patients did not have SI usage whereas 1323 (4.9%) patients had chronic preoperative SI usage. Following adjustment on multivariate analyses, compared to the non-SI usage cohort, patients who used SI had an increased risk of urinary tract infections (UTIs) (OR 1.87; p = 0.009) and septic shock (OR 7.14; p = 0.002). There were no differences in mortality between the two cohorts (p = 0.058). Discussion and Conclusion: Chronic pre-operative SI use is an independent risk factor for septic shock and UTIs following primary SA. Surgeons and patients should be aware of these risks to better inform patient counseling and surgical decision making.
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Background: Clinical decision-making often relies on evidence-based medicine, derived from objective data with conventional and rigorous statistical tests to evaluate significance. The literature surrounding rehabilitation after rotator cuff repair (RCR) is conflicting, with no defined standard of practice. Purpose: To determine the fragility index (FI) and the fragility quotient (FQ) of randomized controlled trials (RCTs) evaluating rehabilitation protocols after RCR. Study Design: Systematic review. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the PubMed, Cochrane Library, and Embase databases for RCTs evaluating rehabilitation protocols after arthroscopic RCRs from 2000 to June 1, 2022. The FI was determined by manipulating the dichotomous outcome events from each article until a reversal of significance with 2 × 2 contingency tables was achieved. The FQ was determined by dividing the FI by the sample size. Results: Fourteen RCTs with 48 dichotomous outcomes were ultimately included for analysis. The mean FI for the included dichotomous outcomes was 4 (interquartile range, 3-6), suggesting that the reversal of 4 events is required to change study significance. The mean FQ was 0.048. Of the RCTs that reported data regarding loss to follow-up, most studies (58.5%) indicated that >4 patients had been lost to follow-up. Conclusion: The results of RCT studies of RCR rehabilitation protocols are moderately fragile, something clinicians should be aware of when implementing study results into practice. We recommend the inclusion of FI and FQ in addition to standard P values when reporting statistical results in future RCTs with dichotomous outcome variables on this topic.
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Postoperative rehabilitation following rotator cuff repair is essential for a positive patient outcome. Each patient should have a program tailored to their individual tear and repair characteristics. Their plan should be advanced according to their progress, with therapist and surgeon communication. The rehabilitation progresses through 4 stages. This begins with a period of immobilization, passive range of motion, and protecting the repair and ends with functional and sport-specific exercises. Rehabilitation advances in progress-based steps during 24 weeks. The rehabilitation process aims to balance healing of the tendon repair and the risk of postoperative stiffness.
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Lesiones del Manguito de los Rotadores , Humanos , Lesiones del Manguito de los Rotadores/cirugía , Manguito de los Rotadores/cirugía , Terapia por Ejercicio , Cuidados Posoperatorios , Ejercicio Físico , Resultado del Tratamiento , Rango del Movimiento Articular , ArtroscopíaRESUMEN
BACKGROUND: Total shoulder arthroplasty (TSA) is increasingly performed safely and efficiently as an outpatient procedure in certain patients. Patient selection is often based on surgeon choice, surgeon expertise, or institutional guidelines. One orthopedic research group released a publicly available shoulder arthroplasty outpatient appropriateness risk calculator that considers patient demographic characteristics and comorbidities with the aim of helping surgeons to predict successful outpatient TSA. This study aimed to retrospectively assess the utility of this risk calculator at our institution. METHODS: Records were obtained for patients undergoing procedure code 23472 at our institution between January 1, 2018, and March 31, 2021. Patients undergoing anatomic TSA in the hospital setting were included. Records were reviewed for demographic characteristics, comorbidities, American Society of Anesthesiologists classification, and surgery duration. These data were entered into the risk calculator to calculate the likelihood of discharge by postoperative day 1. Charlson Comorbidity Index, complications, reoperations, and readmissions were also collected from patient records. Statistical analyses assessed the model's fit with our patient cohort and compared outcome measures between inpatient and outpatient groups. RESULTS: Of the 792 patients whose records were initially obtained, 289 met the inclusion criteria of anatomic TSA performed in the hospital setting. Of these patients, 7 were excluded because of missing data, leaving 282 patients: 166 (58.9%) in the inpatient group and 116 (41.1%) in the outpatient group. We found no significant differences in mean age (66.4 years in inpatient group vs. 65.1 years in outpatient group, P = .28), Charlson Comorbidity Index (3.48 vs. 3.06, P = .080), or American Society of Anesthesiologists class (2.58 vs. 2.66, P = .19). Surgery time was longer in the inpatient group than the outpatient group (85 minutes vs. 77 minutes, P = .001). Overall complication rates were low (4.2% in inpatient group vs. 2.6% in outpatient group, P = .07). Readmissions and reoperations did not differ between groups. There was no difference in the average percentage likelihood of same-day discharge (55.4% in inpatient group vs. 52.4% in outpatient group, P = .24), and a receiver operating characteristic curve to assess fit with the risk calculator demonstrated an area under the curve of 0.55. DISCUSSION: The shoulder arthroplasty risk calculator performed similarly to chance when retrospectively predicting discharge within 1 day after TSA in our patients. Complications, readmissions, and reoperations were not higher after outpatient procedures. Risk calculators for determining whether a patient should be admitted after TSA should be used cautiously because they may not provide measurable benefit over the use of surgeon experience and expertise in discharge decision making, and other factors may be relevant in the decision to perform outpatient TSA.
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Artroplastía de Reemplazo de Hombro , Humanos , Anciano , Artroplastía de Reemplazo de Hombro/efectos adversos , Estudios Retrospectivos , Pacientes Ambulatorios , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , HospitalizaciónRESUMEN
INTRODUCTION: Acromion and scapular spine stress fractures can be catastrophic complications following reverse shoulder arthroplasty (RSA). A variety of host, implant, and technical factors have been identified that increase the risk of this complication. The glenoid component in particular has been closely evaluated for its impact on rates of stress fractures following RSA. The goal of this biomechanical study is to evaluate if humeral stem version has an impact on acromion and scapular spine strain after RSA. METHODS: Eight cadaveric specimens were tested on a custom dynamic shoulder frame. Commercially available RSA components were implanted with the humeral component inserted in 0° of retroversion. Acromion and scapular spine strain were measured at 0°, 30°, and 60° of abduction using strain rosettes secured to the acromion and scapular spine in the typical locations for Levy type II and type III stress fractures, respectively. The humeral stem was then removed and reimplanted in 30° of retroversion and the measurements were repeated. Student t test was performed to analyze the relationship between humeral stem version and acromion and scapular spine strain at various abduction angles. RESULTS: Strain at the both the acromion and scapular spine were found to have no significant difference at any abduction angle when comparing 0° and 30° version of the humeral stem. With 0° and 30° versions pooled together, there is significantly lower acromion and scapular spine strain at 60° of abduction when compared to 0° of abduction (strain at 0° abduction - strain at 60° abduction: acromion 313.1 µêª; P = .0409, Scapular spine 304.9 µêª; P = .0407). There was no significant difference in strain at either location when comparing 0° of abduction to 30° of abduction and when comparing 30° of abduction to 60° of abduction. CONCLUSIONS: This biomechanical study found no significant difference in scapular spine and acromion strain after RSA when comparing variations in humeral stem version. There does appear to be lower strain at both the acromion and scapular spine at 60° of abduction when compared to 0° of abduction regardless of stem version.
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Artroplastía de Reemplazo de Hombro , Fracturas por Estrés , Articulación del Hombro , Humanos , Acromion/cirugía , Artroplastía de Reemplazo de Hombro/efectos adversos , Fracturas por Estrés/etiología , Articulación del Hombro/cirugía , Rango del Movimiento Articular , Húmero/cirugíaRESUMEN
Disparities in the access to, utilization of, and outcomes after orthopaedic surgery are a notable problem in the field that limits patients' ability to access the highest level of care and achieve optimal outcomes. Disparities exist based on numerous sociodemographic factors, with sex and race/ethnicity being two of the most well-studied factors linked to disparities in orthopaedic care. These disparities cross all subspecialties and tend to negatively affect women and racial/ethnic minorities. The increased recognition of the disparities in orthopaedic care has been paralleled by an increased recognition of the lack of diversity among orthopaedic surgeons. Although efforts are being made to improve the representation of women and underrepresented minorities among orthopaedic surgeons, the numbers, particularly of racial and ethnic minorities, show little improvement. The lack of gender and racial diversity among orthopaedic surgeons may be one of many factors related to the gender and racial disparities seen in orthopaedic care. Patients may prefer a provider that they can better identify with and that may affect care. Orthopaedic surgery as a specialty must continue to work to foster an inclusive environment and make concerted efforts to improve diversity through the recruitment of women and underrepresented minorities, among others, for the benefit of patients, surgeons, and the continued growth of the field as a whole.
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Procedimientos Ortopédicos , Ortopedia , Humanos , Femenino , Estados Unidos , Etnicidad , Grupos MinoritariosRESUMEN
BACKGROUND: Despite strong evidence supporting the efficacy of rotator cuff repair (RCR), previous literature has demonstrated that socioeconomic disparities exist among patients who undergo surgery. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation after RCR. METHODS: Patients with Medicare, Medicaid, or commercial payor-type insurance who underwent primary open or arthroscopic RCR between 2010 and 2019 were identified using a large national database. Ninety-day incidence of medical complications, emergency department (ED) visit, and hospital readmission, as well as 1-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated. Propensity-score matching was used to control for patient demographic factors and comorbidities as covariates. RESULTS: A total of 113,257 Medicare, 23,074 Medicaid, and 414,447 commercially insured patients were included for analysis. Medicaid insurance was associated with an increased 90-day risk of various medical complications, ED visit (odds ratio [OR]: 2.87; P < .001), and 1-year revision RCR (OR: 1.60; P < .001) compared with Medicare insurance. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit (OR: 2.98; P < .001), and hospital readmission (OR: 1.56; P = .002), as well as 1-year risk of revision RCR (OR: 1.60; P < .001) and conversion to arthroplasty (OR: 1.4358; P < .001) compared with commercially insured patients. Medicaid insurance was associated with a decreased risk of conversion to arthroplasty compared with Medicare patients (OR: 0.6887; P < .001). Medicaid insurance was associated with higher 1-year cost of care compared with patients with both Medicare (P < .001) and commercial insurance (P < .001). DISCUSSION: Medicaid insurance is associated with increased rates of medical complications, health care utilization, and reoperation after rotator cuff surgery, despite controlling for covariates. Medicaid insurance is also associated with a higher 1-year cost of care. Understanding the complex relationship between sociodemographic factors, such as insurance status, medical comorbidities, and outcomes, is necessary to ensure optimal health care access for all patients and to allow for appropriate risk stratification.
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Lesiones del Manguito de los Rotadores , Manguito de los Rotadores , Humanos , Anciano , Estados Unidos , Manguito de los Rotadores/cirugía , Reoperación , Lesiones del Manguito de los Rotadores/cirugía , Lesiones del Manguito de los Rotadores/etiología , Estudios Retrospectivos , Medicare , Artroplastia/efectos adversos , Aceptación de la Atención de Salud , Artroscopía/efectos adversosRESUMEN
BACKGROUND: Radial head excision (RHE) has been shown to increase contact pressures within the ulnohumeral joint. Radiocapitellar interposition arthroplasty (RCIA) with the use of a soft tissue graft is an alternative for the treatment of isolated radiocapitellar arthritis or with failure of radial head replacement. We investigated contact pressures and contact area within the ulnohumeral joint after RHE compared to RCIA with dermal autograft. METHODS: Six fresh-frozen cadaver elbows were tested on a custom dynamic elbow frame. A pressure sensor was inserted into the intact elbow joint, and mean contact pressure, peak contact pressure, contact area, and force within the ulnohumeral joint were recorded at 0°, 30°, 60°, 90°, and 120° of flexion as a valgus load was applied to the elbow. The radial head was then excised and specimens were retested. Finally, a dermal graft matched to the size of the resected radial head was inserted in the radiocapitellar space and the specimens were tested a third time. RESULTS: At 90° of flexion, contact pressure within the ulnohumeral joint was significantly lower with RCIA compared with RHE (110.8 kPa vs 216.8 kPa; P = .013). The mean peak contact pressure was also significantly lower with RCIA compared with RHE at 90° (279.4 vs 626.7 kPa; P = .025). No statistically significant differences were seen in mean contact area or force between the 3 testing conditions at any flexion position. CONCLUSION: RCIA with a dermal graft reduced contact pressures within the ulnohumeral joint compared to RHE at 90° of flexion without a significant change in contact area or contact force.
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Artroplastia , Articulación del Codo , Humanos , Fenómenos Biomecánicos , Radio (Anatomía)/cirugía , Codo/cirugía , Articulación del Codo/cirugía , Rango del Movimiento Articular , CadáverRESUMEN
Background: Small changes in deltoid tension and moment arm due to glenosphere lateralization may be associated with an increase in acromion or scapular spine strain in reverse shoulder arthroplasty (RSA), which can lead to stress fracture. The coracoacromial ligament (CAL) may be protective and lower the strain seen on the acromion or scapular spine. This biomechanical study investigated the impact of glenosphere lateralization and CAL integrity on acromion and scapular spine strain after RSA. Methods: Ten cadaveric specimens were tested on a custom dynamic shoulder frame. Acromial and scapular spine strain were measured at 0°, 30°, and 60° of abduction using strain rosettes fixed to the acromion (Levy Type 2) and the scapular spine (Levy Type 3). Specimens were first tested with a standard commercially available RSA implant with zero lateralization and then subsequently with the +3 and +6 lateralizing glenospheres for that implant. The CAL was then cut in each specimen and testing was repeated with the 0, +3, and +6 glenospheres. Maximal strain was recorded at both the acromion and scapular spine and analysis of variance compared strain across various abduction angles and glenospheres with and without CAL transection. Results: In the intact CAL group, maximal strain decreased significantly at the acromion with abduction from 0° to 30° and 0° to 60°, however, at the scapular spine abduction did not significantly impact strain. Maximal strain decreased significantly with increasing abduction from 0 to 30 and 0 to 60 at both the acromion and scapular spine in the cut CAL group. Average strain at the acromion was significantly higher in the cut group (844.7 µÎµ) versus the intact group (580.3 µÎµ), a difference of 31.3% (P = .0493). Average strain at the scapular spine, did not differ in the cut group (725 µÎµ) compared with the intact group (787 µÎµ) (P = .3666). There were no statistically significant differences in acromial or scapular spine strain between various levels of glenosphere lateralization in either the cut or intact state. Conclusion: In this biomechanical study, arm abduction decreased acromial and scapular spine strain following RSA. Cutting the CAL significantly increased strain at the acromion, and did not significantly alter strain at the scapular spine for all angles of abduction, differing from prior literature. Glenosphere lateralization did not have a significant effect on strain at the levels studied regardless of CAL status. Continued study of the complexion relationship between surgical and implant factors on strain following RSA is needed.