The surgical treatment of proximal humerus fractures 2010-2019: United States national case volume and incidence trends.

Background: Proximal humerus fractures are the third most common fracture type for patients between the ages of 65 and 89 and occur more frequently in women than men. Given the variety of surgical treatments for proximal humerus fractures, the aim of this study was to (1) report United States national volume and incidence estimates for surgical management of proximal humerus fractures to better understand the changing practice over the past decade and (2) to analyze differences in volume and incidence among age groups, sex, and geographic region. Methods: Using IBM Marketscan national database, all patients that underwent open reduction internal fixation (ORIF), hemiarthroplasty, or reverse total shoulder arthroplasty (RTSA) between 2010 and 2019 were identified with Current Procedural Terminology codes. The dataset was further stratified to identify patients treated for proximal humerus fractures. IBM Marketscan provided discharge weights that were used to determine estimated national annual volumes of each procedure in IBM SPSS Statistics software (IBM Corp., Armonk, NY, USA). Volume and incidence were adjusted per 1,000,000 persons and calculated for subgroups according to age group, sex, and geographical region. The United States Census Bureau annual population data was used for all incidence calculations. Results: Over the past decade, the total volume and incidence of surgically treated proximal humerus fractures increased by 13% and 5%, respectively. Although overall incidence decreased, ORIF remained the most common surgical treatment. The greatest decrease in volume and incidence of ORIF occurred in patients ≥75. The incidence of ORIF treatment increased in the South and West while it decreased in the Northeast and Midwest. Total volume and incidence of HA decreased between 2010 and 2019 and this trend remained among all subgroups. Total volume and incidence of RTSA increased by over 300%. The incidence of males and females receiving RTSA increased by 266% and 320%, respectively. Volume and incidence of RTSA increased across all age groups. Volume and incidence of RTSA increased in the Midwest, South, and Western regions while it remained unchanged in the Northeast. Conclusion: Surgical management trends of proximal humerus fractures have changed greatly over the past decade. ORIF remains the most common surgical treatment for proximal humerus fractures. HA has fallen out of favor while RTSA has seen significant increases in usage across sex, age groups, and geographic regions. These trends represent a change in practice for treating proximal humerus fractures by considering all patient and fracture characteristics when opting for surgical management.

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65.

Background: To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors. Methods: We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant. Results: A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001). Conclusions: The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner.

BACKGROUND: Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS: This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS: A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS: A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

The Top 100 Classical and Contemporary Papers on Elbow Surgery: A Trend Analysis of Elbow Surgery Literature.

INTRODUCTION: Bibliometric analyses provide an aggregate of the most frequently cited literature in a given field. The purpose of this study was to analyze the top 100 most-cited classical and contemporary papers relating to elbow surgery to serve as a reference for surgeons and trainees for educational and research purposes. METHODS: A search was conducted for all papers containing the term "elbow" in the categories Orthopedics, Surgery, and Sports Science in the Clarivate Web of Science. Classical papers were those published from 1980 to 2009, and contemporary papers were those published from 2010 to 2019. Articles were assessed by country of origin, authors and their credentials, parent journal, level of evidence, and topic. RESULTS: Citation frequency ranged from 86 to 867. Among the classical group, there were more level IV papers compared with level I papers; however, the opposite was true in the contemporary group. The most common topic in the classical group was elbow anatomy and function, and the most common topic in the contemporary group was lateral epicondylitis and medial epicondylitis and associated therapies. DISCUSSION: This bibliometric analysis serves to help guide surgeons and trainees on the highly cited articles and important topics in elbow surgery, demonstrating a shift to prospective randomized controlled trials in recent years. LEVEL OF EVIDENCE: Level V (Systematic Review with Level V as Lowest LOE).

Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis.

INTRODUCTION: Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). METHODS: Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. RESULTS: Comparing 25 MR to 72 SI cases, MR significantly improved both inclination (P < .001) and version (P < .001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. CONCLUSION: MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Upper Extremity Fractures in the Emergency Department: A Database Analysis of National Trends in the United States.

BACKGROUND: Upper extremity (UE) fractures are a common reason for emergency department (ED) visits, but recent data on their epidemiology are lacking. This study aimed to describe the incidence, demographics, patient characteristics, and associated health care factors of UE fractures, hypothesizing that they would remain prevalent in the ED setting. METHODS: Using the Nationwide ED Sample database, patients presenting to the ED with UE fractures in 2016 were identified, and population estimates were used to calculate incidence rates. Data on insurance status, trauma designation, cost, and teaching status were analyzed. RESULTS: The study identified 2 118 568 patients with UE fractures, representing 1.5% of all ED visits in 2016. Men accounted for 54.2% of UE fractures, with phalangeal fractures being most common. Distal radius and/or ulna fractures were most common in women (30.4%). The greatest proportion of UE fractures (23.2%) occurred in patients aged 5 to 14 years (1195.5 per 100 000). Nontrauma centers were the most common treating institutions (50.4%), followed by level I (19.5%), II (15.3%), and III (12.8%) centers. The greatest proportion of fractures (38.3%) occurred in the southern United States. Emergency department cost of treatment was almost 2-fold in patients with open UE fractures compared with closed. CONCLUSION: This study provides important epidemiological information on UE fractures in 2016. The incidence rate of UE fractures in the ED has remained high, with most occurring in the distal radius, phalanges, and clavicle. In addition, UE fractures were most common in younger patients, men, and those in the southern United States during the summer. These findings can be useful for health care providers and policymakers when evaluating and treating patients with UE fractures.

A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019.

PURPOSE: The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States. METHODS: The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region. RESULTS: From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%). CONCLUSIONS: Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids.

BACKGROUND: Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve. METHODS: Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared. RESULTS: A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not. CONCLUSION: Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list.

BACKGROUND: In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. METHODS: Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. RESULTS: Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001). CONCLUSIONS: There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Preoperative Depression Is Associated With Increased Complications Following Distal Radius Fracture Surgery.

BACKGROUND: Depression is a known risk factor for inferior outcomes after orthopedic procedures, but its specific relationship with distal radius fractures remains unknown. This study investigates the relationship between preoperative diagnosed depression and common postoperative complications occurring within the first year after open reduction internal fixation (ORIF) for distal radius fractures. METHODS: This retrospective study used Truven MarketScan database and the Current Procedural Terminology (CPT) codes to identify distal radius fracture patients who underwent ORIF in the United States between January 1, 2009, and December 31, 2019. International Classification of Diseases (ICD) codes were used to identify patients with and without a diagnosis of preoperative depression. Univariate, multivariate, t test, and χ2 analyses were performed to determine the association between preoperative depression and postoperative complications following a distal radius fracture surgery. RESULTS: Of the 75 098 eligible patients, 9.9% had at least one ICD code associated with preoperative depression. Preoperative depression was associated with increased odds for surgical site infection (odds ratio [OR] 1.25, confidence interval [CI] 1.14-1.37), emergency department visits for postoperative pain (OR 1.28, CI 1.15-1.36), hardware complication (OR 1.18, CI 1.07-1.30), removal of hardware within 1 year (OR 1.16, CI 1.09-1.27), wound complication (OR 1.17, CI 1.08-1.27), and 30-day readmission (OR 1.21, CI 1.07-1.31). CONCLUSIONS: Preoperative diagnosed depression is associated with increased complications following distal radius fracture surgery. These results can help guide preoperative and postoperative protocols in these higher risk patients. More research is needed to investigate if depression is a modifiable risk factor, as depression treatment could potentially improve postsurgical outcomes.

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report.

CASE: A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA. CONCLUSION: At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique.

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy.

Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient's history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.

Cubital Tunnel Syndrome: Does a Consensus Exist for Diagnosis?

PURPOSE: Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity. We aimed to determine a consensus among experts using the Delphi method for clinical criteria that could be validated further for the diagnosis of CuTS. METHODS: The Delphi method was used for establishing a consensus among a group of expert panelists, comprising 12 hand and upper-extremity surgeons, who ranked the diagnostic clinical importance of 55 items related to CuTS on a scale from 1 (least important) to 10 (most important). The average and SDs of each item were calculated, and Cronbach α was used to assess homogeneity among the panelist-ranked items. RESULTS: All panelists answered the 55-item questionnaire. A Cronbach α value of 0.963 was obtained on the first iteration. The top criteria that were considered most clinically relevant to the diagnosis of CuTS among the group were determined based on the most highly ranked and correlated items among the expert panelist group. The criteria based on which there was agreement were as follows: (1) paresthesias in ulnar nerve distribution, (2) symptoms precipitated by increased elbow flexion/positive elbow flexion tests, (3) positive Tinel sign at the medial elbow, (4) atrophy/weakness/ late findings (eg, claw hand of the ring/small finger and Wartenberg or Froment sign) of ulnar nerve-innervated muscles of the hand, (5) loss of two-point discrimination in ulnar nerve distribution, and (6) similar symptoms on the involved side after successful treatment on the contralateral side. CONCLUSIONS: Our study demonstrated a consensus among an expert panelist group of hand and upper-extremity surgeons on potential diagnostic criteria for CuTS. This consensus on diagnostic criteria may help clinicians readily diagnose CuTS in a standardized form; however, further weighting and validation are necessary prior to the development of a formal diagnostic scale. CLINICAL RELEVANCE: This study is the first step in producing a consensus on how to diagnose CuTS.

Prolonged Opioid Use Following Distal Radius Fracture Fixation: Who Is at Risk and What are the Consequences?

Purpose: Opioid pain medication is most commonly prescribed after distal radius fracture fixation, and there is high variability in the quantity and duration prescribed. Comorbidities, including substance use and depression, have been associated with higher consumption habits, and increased sizes of postoperative opioid prescriptions have been previously linked to an increasing risk of chronic opioid use and opioid use disorder. The purpose of this study was to investigate opioid prescription patterns after distal radius fracture fixation and identify patient-specific risk factors associated with increased opioid prescription refills. Methods: A retrospective review of 34,629 opioid-naïve patients was conducted using the IBM MarketScan database. The database was queried to identify patient records from January 2009 to December 2017. Demographic, comorbidity, complication data, and prescription pharmacy claims were analyzed. Patients were sorted according to the duration of postoperative prescription refills of opioid pain medication. Results: Seventy-three percent of the patients required no additional refills outside the perioperative window. Twenty percent required additional refill prescriptions, and 6.4% of patients continued to fill the opioid medication beyond 6 months after surgery. Multiple factors increased the risk of increased opioid use, including medical and surgical complications, substance use, diabetes, cardiovascular disease, and obesity. Patients with a longer duration of opioid use after surgery had higher rates of medical and surgical complications. Perioperative prescription quantities were 62.9, 78.6, and 83.3 tablets for no refill, refill (<6M), and prolonged-use groups (>6M), respectively. Conclusions: Patients who underwent distal radius fracture fixation were at greater odds for prolonged opioid use after surgery in the presence of comorbid cardiovascular, renal, metabolic, and mental health illnesses and postoperative medical and surgical complications. A greater understanding of patient-specific factors for prolonged opioid consumption after distal radius fracture fixation can help providers identify at-risk patients who would benefit from a tailored approach to counseling and multimodal pain management. Patients should be educated on these risks associated with their surgery and be provided with alternative medical options and health care resources to optimize pain control and reduce their need for opioid medication as their primary tool for pain relief. Type of study/level of evidence: Therapeutic III.

Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain.

CASE: A 74-year-old male patient presenting with chronic radiating shoulder pain, paresthesias, and weakness had previously undergone reverse shoulder arthroplasty and anterior cervical discectomy and fusion for an irreparable cuff tear and cervical radiculopathy, respectively. After being diagnosed with neurogenic thoracic outlet syndrome and undergoing physiotherapy, the patient's recalcitrant condition was surgically managed with arthroscopic pectoralis minor tenotomy, suprascapular nerve release, and brachial plexus neurolysis. CONCLUSION: This ultimately led to complete pain relief and improved function. By sharing this case, we aim to shed light on this overlooked pathology and help prevent unnecessary procedures for others suffering from similar conditions.

Trends and projections in surgical stabilization of glenohumeral instability in the United States from 2009 to 2030: rise of the Latarjet procedure and fall of open Bankart repair.

BACKGROUND: Advances in surgical techniques have improved the ability to address recurrent glenohumeral instability via arthroscopic capsulolabral repair and bone-restoring procedures such as the Latarjet procedure. Given the paucity of studies analyzing temporal trends in the surgical management of glenohumeral instability, the purpose of this study was to assess trends in the treatment of anterior, posterior, and multidirectional instability over a 10-year period and model projections to 2030. METHODS: Using the IBM Watson MarketScan national database, we identified all patients who underwent glenohumeral instability procedures from 2009 to 2018. Procedures were identified using Current Procedural Terminology codes for open Bankart, Latarjet, anterior bone block, posterior bone block, multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weights provided by the database were used to calculate national estimates. US Census Bureau annual population data were used to calculate incidence. Future projections to 2030 were modeled using Poisson and linear regression. RESULTS: There were an estimated 446,072 glenohumeral instability cases from 2009 to 2018. The per capita incidence (per 100,000) remained constant, from 14.8 in 2009 to 14.5 in 2018. Arthroscopic Bankart procedures comprised the highest number of procedures throughout the study period, accounting for 89% of all procedures in 2009 and 93% in 2018. The number of open Bankart procedures decreased by 65% from 2009 to 2018, whereas the number of Latarjet procedures showed a 250% increase over the same period. Patient demographics did not change over the study period, and male patients aged 18-25 years comprised the largest demographic group undergoing anterior instability procedures. Multidirectional instability procedures exhibited the least pronounced sex differences. Future modeling from 2018 to 2030 projected a continued steady rise in arthroscopic Bankart procedures (from 40,000 to 49,000 cases/yr), rapid growth in Latarjet procedures (from 1370 to 4300 cases/yr), and continued decline in open Bankart procedures (from 1000 to 250 cases/yr). CONCLUSIONS: Arthroscopic Bankart repair continues to be the most common glenohumeral instability procedure in the United States. From 2009 to 2018, the incidence of open Bankart procedures declined whereas the incidence of Latarjet procedures markedly increased. Future projections to 2030 mirrored these findings. These data may provide an enhanced understanding of the evolution of surgical treatment of glenohumeral instability within the United States, laying the foundation for continued prospective studies into the appropriate indications and advancements in surgical techniques.