Social Media Use and Patient Ratings in Shoulder and Elbow Surgeons: How Many 'Likes' for Five Stars?

INTRODUCTION: Social media plays an important role in healthcare and physician selection by facilitating direct communication with patients and impacting physician ratings. A concern however is the increased online scrutiny and negative impact on patient satisfaction with these connections. This study aimed to investigate whether social media activity by fellowship-trained shoulder and elbow surgeons impacts patient's perceptions and ratings on physician rating websites (PRWs). MATERIALS AND METHODS: The American Shoulder and Elbow Surgeons (ASES) physician directory was used to identify currently practicing shoulder and elbow surgeons in the US. Physician ratings were collected from Healthgrades, Google reviews, and Vitals. The surgeons were divided into two groups: social media users (SMU) and non-social media users (NSMU). The association of social media use with online physician ratings was evaluated using simple and multilinear regressions. RESULTS: A total of 385 ASES surgeons were included and 21.3% were SMU. SMU were younger (mean age, 48 years) compared to NSMU (mean age, 51 years) (p = 0.01), all other demographics were comparable including sex (p = 0.797), medical degree (MD or DO) (p = 0.114), and geographic location within the US (p = 0.49). SMU had significantly higher ratings on Healthgrades (p<0.001) and Vitals (p<0.001). However, social media use did not impact the total number of ratings on PRWs. Additionally, surgeons who utilized Facebook had higher physician ratings and number of website reviews on Healthgrades (p = 0.028 and p=0.014, respectively). In addition, surgeons who used Twitter had higher ratings on Healthgrades (p<0.001) and Vitals (p=0.001). Surgeons with a greater average number of likes per post on Twitter had significantly higher average ratings across all three sites (p=0.004). Surgeons with a greater number of Twitter followers and greater average number of likes per post had significantly higher average ratings on Healthgrades (p=0.052 and p=0.005, respectively) while surgeons with a greater average number of likes per post had significantly higher average ratings on Vitals (p=0.006). Finally, surgeons with a greater average posting frequency on Instagram had significantly higher average ratings across all websites (p=0.029). CONCLUSION: Shoulder and elbow surgeons who use Twitter and Facebook had significantly higher online ratings. However, the increased use of these platforms in terms of post content, post frequency, comments, and number of followers was not as influential on PRWs. This suggests that social media is an important marketing and outreach method for orthopedic surgeons to improve their ratings and patient reviews.

Despite an Advanced Readability for the General Population, ChatGPT-3.5 Can Effectively Supplement Patient-Related Information Provided by the Treating Surgeon Regarding Common Questions About Rotator Cuff Repair.

PURPOSE: The purpose of this study was to investigate the accuracy of ChatGPT's responses to frequently asked questions (FAQ) prior to rotator cuff repair surgery. METHODS: The ten most common FAQs related to rotator cuff repair were compiled from four institution websites. Questions were then input into ChatGPT-3.5 in one session. The provided ChatGPT-3.5 responses were analyzed by two orthopedic surgeons for reliability, quality, and readability using The Journal of the American Medical Association (JAMA) Benchmark criteria, the DISCERN score, and the Flesch-Kincaid Grade Level. RESULTS: The JAMA Benchmark criteria score was 0, indicating the absence of reliable source material citations. The mean Flesch-Kincaid Grade Level was 13.4 (range, 11.2-15.0). The mean DISCERN score was 43.4 (range, 36-51) indicating that the quality of the responses overall was considered fair. All responses cited making final decision-making to be made with the treating physician. CONCLUSION: ChatGPT-3.5 provided substandard patient-related information in alignment with recommendations from the treating surgeon regarding common questions around rotator cuff repair surgery. Additionally, the responses lacked reliable source material citations and the readability of the responses was relatively advanced with a complex language style. CLINICAL RELEVANCE: The findings of this study suggest that ChatGPT-3.5 may not effectively supplement patient-related information in the context of recommendations provided by the treating surgeon prior to rotator cuff repair surgery.

Outcomes Following Revision Reverse Shoulder Arthroplasty for Infection.

BACKGROUND: In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and healthcare systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared to rRSA for non-infectious causes. METHODS: Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into two cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi), and (2) rRSA due to non-infectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test (SST), Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California-Los Angeles (UCLA), Shoulder Arthroplasty Smart score (SAS), and active range of motion (ROM) were collected preoperatively and at a minimum one year follow-up. Postoperative complications and revision rates were also collected. RESULTS: A total of 93 patients (n=19 rRSAi group, n=74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the two groups. Postoperative complication rates and revision rates were comparable between the groups. CONCLUSION: Revision reverse shoulder arthroplasty due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for non-infectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to non-infectious causes. Further efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

The Sex or Race of Program Directors May Not Play a Significant Role in Impacting Diversity Among Orthopaedic Surgery Residents.

PURPOSE: To identify the influence of residency program characteristics, including the presence of under-represented minorities in medicine (URiM) and/or female program directors (PDs), on the race and sex distribution of orthopaedic surgery residency trainees. METHODS: All active and Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs from 2017-2021 that reported usable information in the Residency Explorer Tool were included. Data collected included program characteristics, as well as faculty and resident sex distribution, ethnicity, race, and demographic characteristics. The PDs' specific sex, ethnicity, race, and demographic characteristics were collected using residency program websites. The prevalence of factors in programs with the top quartile of female and URiM residents was compared with that in programs with the bottom 3 quartiles. RESULTS: Data were obtained from 148 of 200 Accreditation Council for Graduate Medical Education-accredited programs (3,694 residents). The 52 excluded programs had no usable information in the Residency Explorer Tool or on an identifiable program website. Overall, 15.9% of residents in orthopaedic surgery residency programs were women and 14% were under-represented minorities. The rates of female PDs and chairs were 12.4% and 6.9%, respectively, whereas those of URiM PDs and chairs were 8.3% and 4.6%, respectively. Programs with more female residents were not associated with female PDs (P = .79) or URiM PDs (P = .48). Programs with a greater percentage of URiM residents were not associated with URiM PDs (P = .16). Larger programs (P = .021) and university-based programs (P = .048) had a greater percentage of female residents. Orthopaedic residency programs with visa sponsorship had a greater percentage of URiM residents (P = .017). CONCLUSIONS: Programs with a higher percentage of female or URiM residents did not show a significant association with having female or URiM PDs. Larger programs and university-affiliated programs were more likely to have a larger percentage of female residents, whereas programs that offered visa sponsorship had a higher percentage of URiM residents. CLINICAL RELEVANCE: This study highlights factors influencing diversity among orthopaedic surgery residents. Although the presence of female or URiM PDs does not influence the percentage of female or URiM residents, other program characteristics such as size, affiliation, and visa sponsorship offer potentially actionable insights for promoting greater diversity in orthopaedic training. Doing so may increase under-represented groups within the field and could ultimately impact patient care and improve health care equity.

Ulnar Collateral Ligament Reconstruction Is Commonly Performed Using a Palmaris Graft and Provides Favorable Patient Outcomes With Variable Return-to-Play and Postoperative Complication Rates: A Systematic Review.

PURPOSE: To systematically review the literature to provide an updated evaluation of postoperative clinical outcomes, return to play (RTP), and postoperative complications after primary ulnar collateral ligament reconstruction (UCLR) in throwing and nonthrowing athletes at minimum 2-year follow-up. METHODS: A literature search was performed on November 25, 2023, by querying the Embase, PubMed, and Scopus online databases using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The inclusion criteria consisted of Level I to IV human clinical studies reporting postoperative outcomes and/or complications after primary UCLR with minimum 2-year follow-up. The exclusion criteria consisted of non-English-language studies; biomechanical, animal, and cadaveric studies; review articles; letters to the editor; and studies not reporting postoperative outcomes or complications. Study quality was evaluated using the Methodological Index for Non-Randomized Studies criteria. The incidence of reported complications among the included studies was extracted. Clinical outcome scores included the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, Andrews-Timmerman (AT) score, and satisfaction score. RTP data were also extracted. RESULTS: A total of 21 studies published from 2006 to 2023, consisting of 2,452 patients (2,420 male patients) with a mean age of 21.7 years (mean range, 12-65 years) and mean follow-up period of 50.5 months (mean range, 24-151.2 months), were included. The mean Methodological Index for Non-Randomized Studies score was 16 (range, 13-20). A total of 46% of patients (1,138 of 2,452) underwent concomitant ulnar nerve transposition. Palmaris graft was the most frequently used method (66.6%; n = 1,799), followed by hamstring graft (26.0%, n = 703). At the final follow-up, mean postoperative KJOC scores ranged from 72.0 to 88.0; mean AT scores, from 83.6 to 98.3; and mean satisfaction scores, from 86.1 to 98.3. The overall RTP rate ranged from 62.5% to 100% at a mean range of 9.5 to 18.5 months. The total incidence of complications ranged from 0% to 31.8%, with 0% to 7.4% of patients undergoing revision surgery. CONCLUSIONS: UCLR was commonly performed using a palmaris graft, with concomitant ulnar nerve transposition reported in 46% of patients. At a mean follow-up of 50.5 months, mean postoperative KJOC scores ranged from 72 to 98.3, AT scores ranged from 83.6 to 98.3, and satisfaction scores ranged from 86.1 to 98.3, with variable RTP rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Rotator cuff tears.

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Massive Irreparable Rotator Cuff Tears Treated With a Tuberoplasty Yield Favorable Clinical Outcomes With Variable Rates of Complications: A Systematic Review.

PURPOSE: To systematically review the patient-reported outcomes and postoperative complications following tuberoplasty for the treatment of massive irreparable rotator cuff tears. METHODS: A literature search was conducted using PubMed and EMBASE computerized databases from database inception to June 2023 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Included studies evaluated clinical outcomes, postoperative complications, and reoperation rates following tuberoplasty for the treatment of massive irreparable rotator cuff tears. Exclusion criteria consisted of non-English language, cadaveric studies, case reports, animal studies, studies with overlapping cohorts, letters to editors, and review articles. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Clinical outcome scores included the visual analog scale for pain, University of California Los Angeles score, and Constant score. RESULTS: Seven studies from 2002 to 2023 consisting of 123 patients with a mean age of 66.5 years (mean range, 63-70.4 years) were included. The mean follow-up time ranged from 18 to 98 months. The mean Methodological Index for Non-Randomized Studies score was 13.5 (range, 13-15). At final follow-up, the mean postoperative visual analog scale pain scores ranged from 2.3 to 2.5, University of California-Los Angeles shoulder score from 27.2 to 27.7, and Constant scores from 59.2 to 90.6. Postoperative active forward flexion and abduction ranged from 131° to 165°, and 123° to 160°, respectively. The change in acromiohumeral distance postoperatively ranged from -1 mm to -0.6 mm. The rate of postoperative complications ranged from 0% to 19% of patients, while 0% to 19% of patients underwent revision surgery to reverse shoulder arthroplasty. CONCLUSIONS: Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations. However, the variable reoperation rates should be considered when counseling patients. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty.

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

Application of risk assessment tools to predict opioid usage after shoulder surgery.

Background: Currently 128 people die daily from opioid-related overdoses in the United States. This burden has instigated a search for viable means to guide postoperative prescription decision-making. The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patient with Pain (SOAPP) are validated risk assessment tools to predict opioid usage in high-risk populations. The purpose of this study was to evaluate the accuracy of these opioid risk assessments and pain intensity scores, including the Patient-Reported Outcomes Measurement Information System (PROMIS), to predict postoperative opioid use and dependence in shoulder surgery. Methods: A retrospective review of 81 patients who underwent shoulder surgery and completed 3 preoperative risk and pain assessments within a single hospital system from 2018 to 2020 was performed. Demographic variables and ORT-O, SOAPP-R (the revised version of the SOAPP assessment), and PROMIS 3a scores were recorded from preoperative assessments. Opioid prescriptions were recorded from Electronic-Florida Online Reporting of Controlled Substances Evaluation. Dependence was defined as opioid prescriptions at or greater than 3 months after surgery. Risk assessment scores were compared and tested against postoperative opioid prescriptions using statistical analyses and logistic regression modeling. Results: In the cohort, there were 36 female and 45 male patients with an average age of 64.5 years and body mass index of 28.0. Preoperatively, the average pain score was 6.2, and 7.8% of patients reported prolonged preoperative narcotics use. The average ORT-O score was 3.0, with 35.8% of patients defined as either medium or high risk, and the average PROMIS pain intensity preoperatively was 10.8. Neither the ORT-O nor the PROMIS pain score were good predictors of postoperative opioid dependence (area under curve = 0.39 and 0.43, respectively). The SOAPP-R performed slightly better (area under curve = 0.70) and was the only assessment with significantly different mean scores between patients with postoperative opioid dependence and those without (33.4 and 24.5, respectively, P = .049) and a moderate correlation to postoperative total morphine equivalents (R = 0.46, P = .007). Conclusion: With recent focus on preoperative risk assessments to predict postoperative opioid use and dependence, it is important to understand how well these tools work when applied to orthopedic patients. While the ORT may be helpful in other fields, it does not seem to be a strong predictor of postoperative opioid use or dependence in patients undergoing various types of shoulder surgery. Future studies are needed to explore the utility of the SOAPP-R in a larger sample and identify tools applicable to the orthopedic population to assist surgeons in screening at-risk patients.

The use of preoperative planning to decrease costs and increase efficiency in the OR.

Background: Shoulder arthroplasty (SA) incurs up to $1.8B per year in societal costs. With the increasing demand for SA and the steady decrease of annual reimbursements for orthopedic procedures, it has become crucial to control costs. In SA, there has been an interest in using preoperative planning software to improve accuracy in positioning and implant selection, ultimately optimizing outcomes. However, the use of preoperative planning to increase efficiency has not been studied. The purpose of this study was to determine if preoperative planning could increase efficiency and decrease costs in the operating room. Methods: This retrospective review included 94 patients who underwent shoulder arthroplasty and had a CT scan with a preoperative plan by a single orthopedic surgeon between 2017 and 2020. The patients were divided based on the use of the preoperative plan during surgery. Group 1 included 65 patients with a preoperative plan used during surgery, and group 2 included 29 patients without a preoperative plan utilized during surgery. Average preparation time, surgical time, time in the operating room, the number of trays sterilized, and postoperative outcomes were analyzed between the two groups. Subanalysis was done to find a statistical difference in the cost of sterilization for both groups. Results: The cohort had 55% males, with an average age of 71 years and an average BMI of 29.9. There were no significant differences between the groups for age, BMI, or ASA class. There was no significant difference between groups in preparation time (group 1: 53.3 min, group 2: 53.1 min P = .924), surgical time (group 1: 119.7 min, group 2: 111.9 min; P = .25), or time in the OR (group 1: 183.2 min, group 2: 173.2 min; P = .156). There was a statistical difference in the number of trays (5 vs. 8; P < .01) and cost of sterilization between groups ($487.30 vs. $842.86; P < .01). No correlation between the number of trays and preparation time (group 1: -0.05, group 2: -0.28) or trays and surgical time was found for either group (group 1: r = -0.31, group 2: r = -0.22). There were no significant differences in postoperative outcomes between the groups. Conclusion: While preoperative planning did not reduce time in the OR for shoulder arthroplasty, it was correlated to a significant reduction in the number and cost of sterilized trays with comparable postoperative outcomes.

Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Housing Security and Discharge Planning Disparities.

Patients undergoing total joint arthroplasty should be screened for housing insecurity. Housing insecurity in the United States ranges from 10% to 15%, which is predisposed to those who are low-income, racial minorities, and unmarried. Osteoarthritic pain has a notable effect on function and quality of life and may prevent many individuals from continuing with their jobs. There is an inexorable, cyclic, structurally reinforced relationship between housing and health: where chronic illness affects housing security leading to issues with access to care and ultimately issues with health status. Housing insecurity is currently an imposed barrier to surgery. However, creative solutions exist to address housing insecurity, such as insurance company waivers, community resources (eg, churches) and organizations (eg, Meals on Wheels), halfway houses, and temporary housing (eg, hotels). Optimization for discharge planning in these vulnerable populations includes short-term stay in rehabilitation or skilled nursing facilities, home health services, or outpatient therapy.

Patients' perception of physical therapy after shoulder surgery.

BACKGROUND: Formal physical therapy (PT) traditionally has been a critical part of postoperative recovery, but recently, because of cost containment, coverage of PT has become limited. Alternatives to formal PT have been proposed, including telerehabilitation, internet-based PT (IBPT), and home-based physician-guided PT. The purpose of this study was to understand patient perceptions of PT, the benefits, perception of improvements, access to PT, and alternative forms of PT after shoulder surgery. METHODS: Eighty patients who underwent orthopedic shoulder surgery were anonymously surveyed at one institution. Demographics, PT access, number of PT sessions, insurance, copayment, patients' perceptions of improvement, and their opinion about IBPT were collected. Answers were designed using Likert-scale or open-ended questions. Descriptive statistics were used to report survey data. Analyses were performed based on demographic variables using independent t-test, chi-square tests, and analysis of variance. RESULTS: Patients attended an average of 16.3 ± 13.8 PT sessions, with 65% ± 32.2 attributing average improvement to their sessions. Average copay was $18 ± 20.8 per session, which 56.1% agreed was reasonable. Almost all patients (94.8%) agreed their therapist took time to educate them. Half (52.5%) disagreed that successful PT could be achieved by IBPT, and 68.6% of patients responded they would not consider using IBPT even after a few in-person sessions. CONCLUSION: Patients have a positive perception of their therapist, cost, number of sessions, and utility of PT to impact improvements after orthopedic shoulder surgery. For IBPT to be a viable alternative, it should involve close engagement of a physical therapist given patients' perceptions of PT.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

BACKGROUND: Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS: Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS: A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS: This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Obesity Disparities.

Thirty five percent of the American population is considered obese (body mass index [BMI] > 30). Obesity disproportionately affects African Americans, Hispanics, and women. Obesity is associated with postoperative complications, including wound complications, infections, and revision total joint arthroplasty (including total hip arthroplasty and total knee arthroplasty). Current BMI benchmarks (many institutions rely on a BMI of 40) selectively preclude patients from having surgery. Patients in these underserved populations can be optimized through the lens of shared decision making through the assessment of food security (eg, food deserts and food swamps), ability to afford healthy food, knowledge of social safety net and community resources to access healthy food, nutrition and weight loss referrals to programs that accept all forms of insurance, weight loss measurements as a percentage of body weight lost instead of BMI cutoffs, pharmacologic modalities, and bariatric surgery.

An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair.

BACKGROUND: In the realm of shoulder surgery, arthroscopic rotator cuff repair (RCR) is one of the most painful procedures and is often associated with higher opioid consumption. The purpose of this study was to evaluate effectiveness of preoperative and postoperative patient education and multimodal pain management to achieve an opioid-free postoperative recovery after RCR. METHODS: Sixty patients who underwent RCR were divided in 2 groups. All patientsreceived an interscalene nerve block and multimodal pain management. The opioid intervention group (OIG) in addition received preoperative education on expectations of pain, non opioid pain protocols, and alternate therapiesto minimize pain as well as customized postoperative instructions. Patients were compared on pain levels, opioid consumption, and outcomes scores preoperatively and at 48 hours, 2 weeks, and final follow-up. Patient-reported outcomes and opioid usage were compared and analyzed using student's t-tests and logistic regression. RESULTS: At 48 hours, 15% of OIG patients reported use of rescue opioids after surgery compared with 100% of control group patients. Zero percent of OIG patients reported opioid use at 2 weeks compared to 90% of control group patients (P = .0196). Patients in both groups showed significant improvements in all outcome scores (P ≤ .05). At 6 weeks, functional, Constant, and satisfaction outcome scores were all higher in the OIG (P < .05). At last follow-up, there were no significant differences for all patient-reported outcomes between groups. CONCLUSIONS: Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes.

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty.

BACKGROUND: Orthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty. METHODS: A retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences. RESULTS: Preoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043). CONCLUSIONS: State-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

Predictors and prescribing patterns of opioid medications surrounding reverse shoulder arthroplasty.

BACKGROUND: Opioid analgesics play an essential role in postoperative pain management; however, they are also associated with high rates of abuse and decreased patient outcomes. With the declaration of the recent opioid crisis, more scrutiny has been placed on physicians and their prescribing habits, and orthopedic surgeons have been shown to be the third-largest providers of opioids. Many patients undergoing reverse shoulder arthroplasty (RSA) have acute and chronic pain and may be prescribed opioids. The purpose of this study was to understand opioid-prescribing patterns across all specialties for patients undergoing RSA. METHODS: A retrospective review of preoperative and postoperative opioid use in 407 patients who underwent RSA from 2012 to 2015 was performed. Demographic data including age, sex, race, ethnicity, body mass index, American Society of Anesthesiologists class, and smoking status were recorded. Opioid prescriptions within 90 days before and after surgery were collected using state-mandated prescription drug-monitoring databases. Prescriber specialty was recorded, and prescriptions were categorized as follows: orthopedic surgery, primary care or internal medicine, pain management and anesthesia, dentistry, and emergency medicine. RESULTS: The cohort was composed of 236 women (58.0%) and 171 men (42.0%). The average age was 71 years. Forty-six percent of patients received preoperative prescriptions, of which 24.7% were written by orthopedic surgeons and 60.0% were written by internal medicine specialists. Preoperatively, 20% of patients received >3 prescriptions for opioids, and postoperatively, 36.4% of patients received >3 opioid prescriptions. Fifty-nine percent of all postoperative prescriptions were written by orthopedists, and 35.2% were written by internal medicine specialists. CONCLUSION: Not surprisingly, orthopedic surgeons prescribed the majority of postoperative prescriptions. Increased awareness, however, of preoperative prescribing habits by other specialty providers may be needed, with communication of their prescriptions to orthopedists, as preoperative use is the strongest predictor of postoperative dependence on opioids. Physicians should be aware of the number of patients receiving multiple prescriptions and their contribution to dependence with continued refills postoperatively. Therefore, surgeons must be more meticulous in assessing opioid consumption before surgery, as well as which providers are writing prescriptions after surgery, to limit opioid dispensation.

Innovative patient education and pain management protocols to achieve opioid-free shoulder arthroplasty.

BACKGROUND: The creation of pain as the fifth vital sign led to skyrocketing opioid prescriptions and a crisis with addiction and abuse among Americans. The purpose of this study was to evaluate the effectiveness of a patient engagement model including education and innovative opioid-free multimodal pain management to achieve an opioid-free recovery after shoulder arthroplasty (SA). METHODS: Fifty patients undergoing SA were divided into 2 groups. In the opioid-free group (OFG), patients received additional preoperative education in combination with an innovative non-opioid multimodal pain management protocol and non-opioid alternatives. Patients were compared regarding pain levels and opioid consumption at 48 hours and at 2 weeks, as well as patient-reported outcome measures, using Student t tests. RESULTS: No significant differences were found in age (average, 69.76 years) (P = .14), American Society of Anesthesiologists grade (average, 2.25) (P = .24), sex, body mass index (average, 29.5) (P = .34), or comorbidity burden. In the OFG, 24% of patients reported use of rescue opioids (<2 pills) within the first 48 hours after surgery with complete cessation by 2 weeks postoperatively. Comparatively, in the control group, 100% of patients reported using opioids in the first 48 hours after surgery and 80% reported still taking opioids at 2 weeks postoperatively. Patients in both groups showed significant improvements in outcome scores (P ≤ .05), with the OFG reporting significantly higher American Shoulder and Elbow Surgeons pain (P = .036) and Constant (P = .005) scores. CONCLUSIONS: Our findings support complete elimination of opioid use by 2 weeks after SA using a patient engagement model with non-opioid-based alternative pain management. The elimination of opioid pain management did not diminish outcomes or patient satisfaction after SA.

How orthopedic surgeons can impact opioid use and dependence in shoulder arthroplasty.

BACKGROUND: Considering that the United States is facing a crisis with opioid misuse and orthopedists are the third largest provider of these prescriptions, it is important to delineate risk factors associated with use and dependence. Our purpose was to identify risk factors for and patient characteristics of increased opioid use and postoperative opioid dependence in total shoulder arthroplasty (TSA) patients. METHODS: This was a retrospective study of 752 TSA patients who underwent surgery in 1 health care system from 2012-2016. Recorded variables included demographics and opioid prescriptions from prescription drug monitoring programs. Preoperative and postoperative opioid dependence was defined as continuous opioid prescriptions for at least 3 months prior to or after surgery. Statistical analyses and odds ratio analyses were performed. RESULTS: Of the 752 patients in total, 241 (32%) became or remained postoperatively dependent whereas 68% (511) were able to wean off of opioids by 3 months. In the preoperatively dependent cohort, only 27% were able to wean off opioids at 1 month and 53%, by 3 months postoperatively. Odds ratio calculations showed that patients with preoperative opioid use had a 3.52 (95% confidence interval, 2.433-5.089) times increased risk of postoperative dependence compared with opioid-naive patients. Of those receiving postoperative opioid refills, 69% were provided these refills by their orthopedic surgeons. DISCUSSION AND CONCLUSIONS: Although the majority of TSA patients weaned off of opioids after surgery, our results demonstrate a 3.5 times higher risk of postoperative dependence in patients who used preoperative opioids. Orthopedists were major contributors to continued postoperative opioid use, and increased efforts to minimize opioid prescriptions before, during, and after TSA may help curtail overuse and dependence. These results highlight the hazard that preoperative opioid use entails for shoulder arthritis patients.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs.

BACKGROUND: Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. PURPOSE/HYPOTHESIS: This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. RESULTS: A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R2 in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs. CONCLUSION: Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.