A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty.

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Diagnostic Evaluation of Prosthetic Joint Infections of the Shoulder: What Does the Literature Say?

The total number of patients with a total shoulder arthroplasty (TSA) is increasing, and the number of patients experiencing a (TSA) prosthetic joint infection (PJI) also will increase. It is important that physicians know how to identify signs of infection, know the common pathogens, and know how to work up a shoulder PJI. This publication reviewed the current literature about presenting signs and symptoms, common shoulder pathogens and how they differ from total knee and hip pathogens, and what images, tests, and procedures can aid in identification of infection.

Muscle activation patterns during active external rotation after reverse total shoulder arthroplasty: an electrophysiological study of the teres minor and associated musculature.

BACKGROUND: Preoperative teres minor insufficiency has been identified as a risk factor for poor restoration of external rotation (ER) after reverse total shoulder arthroplasty (RTSA). However, there has been little investigation regarding muscle activation patterns generating ER. This prospective study sought to determine the timing and activation levels of the shoulder girdle musculature during ER in well-functioning RTSAs with an intact teres minor using a lateralized design. METHODS: Patients who underwent RTSA ≥1 year previously with functional ER, an American Shoulder and Elbow Surgeons (ASES) score >70, superior rotator cuff deficiency, and an intact teres minor were identified. Electrophysiological and kinematic analyses were performed during ER in the modified neutral position (arm at side with 90° of elbow flexion) and in abduction (AB) (shoulder abducted 90° with 90° of elbow flexion). Dynamometer-recorded torque and position were pattern matched to electromyography during ER. The root-mean-square and integrated electromyography (in microvolts × milliseconds with standard deviation [SD]), as well as median frequency (MF) (in hertz with SD), were calculated to determine muscle recruitment. Pair-wise t test analysis compared muscle activation (P < .05 indicated significance). RESULTS: After an a priori power analysis, 16 patients were recruited. The average ASES score, visual analog scale pain score, and ASES subscore for ER in AB ("comb hair") were 87.7, 0.5, and 2.75 of 3, respectively. In AB, muscle activation began with the upper trapezius, middle trapezius, and latissimus dorsi, followed by the anterior deltoid activating to neutral. With ER beyond neutral, the teres major (9.6 µV × ms; SD, 9.2 µV × ms) initiated ER, followed by the teres minor (14.1 µV × ms; SD, 18.2 µV × ms) and posterior deltoid (11.1 µV × ms; SD, 9.3 µV × ms). MF analysis indicated equal contributions of the teres major (1.1 Hz; SD, 0.5 Hz), teres minor (1.2 Hz; SD, 0.4 Hz), and posterior deltoid (1.1 Hz; SD, 0.4 Hz) in ER beyond neutral. In the modified neutral position, the upper trapezius and middle trapezius were not recruited to the same level as in AB. For ER beyond neutral, the teres major (9.5 µV × ms [SD, 9 µV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), teres minor (11.4 µV × ms [SD, 15.1 µV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), and posterior deltoid (8.5 µV × ms [SD, 8 µV × ms]; MF, 1.2 Hz [SD, 0.3 Hz]) were activated in similar sequence and intensity as AB. No differences in muscle activation duration or intensity were noted among the teres major, teres minor, and posterior deltoid (P > .05). CONCLUSION: Active ER after RTSA is complex and is not governed by a single muscle-tendon unit. This study establishes a sequence, duration, and intensity of muscle activation for ER in well-functioning RTSAs. In both tested positions, the teres major, teres minor, and posterior deltoid function equally and sequentially to power ER.

Superior humeral head osteophytes are associated with rotator cuff insufficiency in glenohumeral osteoarthritis: a retrospective analysis.

PURPOSE: The primary goal of this study was to investigate whether superior humeral head osteophyte (SHO) size is associated with rotator cuff insufficiency, including rotator cuff tear (RCT), supraspinatus tendon thickness, and fatty infiltration of the rotator cuff muscles. METHODS: Patients ≥ 18 years who were diagnosed with glenohumeral osteoarthritis were retrospectively reviewed. SHO size was determined by radiograph. MRI measured SHO and RCT presence, type, and size; supraspinatus tendon thickness; and fatty infiltration of rotator cuff musculature. RESULTS: A total of 461 patients were included. Mean SHO size was 1.93 mm on radiographs and 2.13 mm on MRI. Risk ratio for a RCT was 1.14. For each 1-mm increase in SHO size on radiograph, supraspinatus tendon thickness decreased by 0.20 mm. SHO presence was associated with moderate-to-severe fatty infiltration of the supraspinatus with a risk ratio of 3.16. CONCLUSION: SHOs were not associated with RCT but were associated with higher risk of supraspinatus FI and decreased tendon thickness, which could indicate rotator cuff insufficiency. LEVEL OF EVIDENCE: IV.

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update.

BACKGROUND: Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS: A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS: A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS: There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

Comparison of triamcinolone and methylprednisolone efficacy and steroid flare reaction rates after shoulder corticosteroid injection: a prospective interrupted time series study.

BACKGROUND: A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions. METHODS: In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection. RESULTS: MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection.

Postoperative Rehabilitation After Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA), including anatomic TSA (aTSA) and reverse TSA (rTSA), has increased in popularity due to reliably good patient outcomes. Postoperative physical therapy (PT) is considered essential to the success of this operation and has become standard practice. The authors present general rehabilitation principles as well as preferred postoperative PT protocols for aTSA and rTSA, which are based on evidence-based literature and the different early postoperative concerns for each of these procedures.

Emerging Technologies in Shoulder Arthroplasty: Navigation, Mixed Reality, and Preoperative Planning.

Shoulder arthroplasty is a rapidly improving and utilized management for end-stage arthritis that is associated with improved functional outcomes, pain relief, and long-term implant survival. Accurate placement of the glenoid and humeral components is critical for improved outcomes. Traditionally, preoperative planning was limited to radiographs and 2-dimensional computed tomography (CT); however, 3-dimensional CT is becoming more commonly utilized and necessary to understand complex glenoid and humeral deformities. To further increase accurate component placement, intraoperative assistive devices-patient-specific instrumentation, navigation, and mixed reality-minimize malpositioning, increase surgeon accuracy, and maximize fixation. These intraoperative technologies likely represent the future of shoulder arthroplasty.

Skeletally Immature Patients With Classic Anterior Cruciate Ligament Bone Bruise Patterns Have a Higher Likelihood of Having an Intact Anterior Cruciate Ligament Compared With Skeletally Mature Patients.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) tears in skeletally immature patients with an ACL bone contusion pattern has been sparsely investigated. The purpose of this study is to investigate whether physeal status has an influence on the likelihood of sustaining an ACL tear when classic bipolar ACL bone bruising pattern is present. METHODS: Magnetic resonance imaging reports were queried for "contusion" on all patients between 6 and 22 years between 2015 and 2019. Images were reviewed to denote all intra-articular pathology and the physeal status of the femur and tibia. The primary outcome was the incidence of ACL tears in patients with the presence of bipolar bone contusions. Fischer exact testing was used to determine associations. RESULTS: Of 499 patients included, 269 of those had bipolar bone contusions. Patients with bipolar bone contusions and ACL tears had a shorter duration between injury and imaging date compared with patients with ACL tears without bipolar bone contusions (6.9 vs. 38.6 d, P =0.05). Patients with an open femoral physis had a higher likelihood of having an intact ACL despite the presence of bipolar bone contusions than patients with a closed femoral physis (10.8% vs. 1.0%, P <0.001). Of patients with bipolar bone contusions, those with an intact ACL were younger than patients with an ACL tear (14.6 vs. 16.4, P =0.017). CONCLUSIONS: Although bipolar bone contusions of the central lateral femoral condyle and posterior lateral tibial plateau are typically found after ACL injury, these bipolar contusions can be found concomitantly with an intact ACL and were more often found in relatively younger patients. Patients who have an open femoral physis have a higher likelihood to have an intact ACL despite the presence of bipolar bone contusions compared with patients who have a closed femoral physis. LEVEL OF EVIDENCE: Level IV-cross-sectional.

The Incidence of Posterolateral Tibial Plateau and Central Lateral Femoral Condylar Impaction Fractures in a Pediatric and Young Adult Population.

BACKGROUND: Posterolateral tibial plateau and central lateral femoral condylar impaction fractures are known to occur in the setting of anterior cruciate ligament (ACL) tears. There have been no prior investigations into the incidence and morphology of posterolateral tibial plateau impaction fractures in the setting of ACL injury in a pediatric population. METHODS: Patients between 9 and 22 years of age with knee magnetic resonance imagings (MRIs) performed demonstrating complete or partial ACL tear were included in this study. MRI reports were reviewed to denote the presence of posterior cruciate ligament, medial collateral ligament, or lateral collateral ligament injury, meniscus tears, cartilage lesions. MRIs were reviewed by 2 fellowship-trained orthopaedic surgeons to denote the presence of posterolateral tibial plateau and central lateral femoral condylar impaction fractures and physeal status of femoral and tibial physes. Statistical analysis performed included χ 2 analysis and the Student t testing. RESULTS: A total of 328 patients with a primary ACL tear were identified. The mean age of patients included was 16.5 years (range: 9.0-21.5). The incidence of posterolateral tibial plateau impaction fractures was 83/328 (25.3%) while the incidence of lateral femoral condylar impaction fractures was 119/328 (36.3%). Bipolar impaction fractures occurred in 37/328 (11.3%). Of the 83 tibial impaction fractures identified, 82 were low-grade morphologic subtypes. Patients with lateral tibial plateau impaction fractures were older than those with no fracture (17.2±2.2 vs. 16.3±2.1, P =0.001). Only 3/38 (7.9%) patients with an open tibial physis sustained a tibial plateau impaction fracture compared with 80/290 (27.6%) with a closed tibial physis (χ 2 value: 6.9, P =0.009). There was no difference in proportion of patients with lateral femoral condylar impaction fractures based on femoral physeal status ( P =0.484). CONCLUSION: The incidence of posterolateral tibial plateau impaction fractures in the setting of ACL tear in a pediatric and young adult patient population appears to be lower while lateral femoral condylar impaction fractures occur more frequently when comparing to previously reported incidences found in adult populations in the literature. Furthermore, posterolateral tibial plateau impaction fractures occur less frequently in those with an open proximal tibial physis and high-grade posterolateral tibial plateau bone loss is exceedingly rare in pediatric and young adult patients. Lateral femoral condylar impaction fractures are associated with lateral meniscal tears and medial meniscal ramp lesions. LEVEL OF EVIDENCE: Level IV-cross-sectional study.

Acute, Traumatic Rotator Cuff Tears Have Smaller Critical Shoulder Angles Than Degenerative Tears.

PURPOSE: To determine whether the critical shoulder angle (CSA) in acute, traumatic rotator cuff tears (RCTs) is consistent with the previously described CSA in chronic degenerative RCTs. METHODS: We performed a multicenter retrospective analysis of 134 patients presenting to 5 surgeons fellowship trained in shoulder and elbow or sports. Preoperative imaging was used to measure the CSA and tear characteristics. Patients were included if they had acute, traumatic full-thickness RCTs documented on advanced imaging and had preoperative Grashey radiographs. Patients were excluded if they had any history of shoulder pain, injury, surgery, or treatment prior to the current episode; were overhead athletes; or had fatty infiltration greater than Goutallier grade 1 on imaging. RESULTS: The mean CSA was 33.5° (standard deviation, 4.1°), and 60% of tears had a CSA of less than 35°, much below the mean of 38.0° and the threshold of greater than 35° in degenerative RCTs. The mean age was 58 years, and 70% of patients were men. Overall, 60% of tears involved the subscapularis, 49% of tears occurred in patients aged 60 years or older, and 18% of patients sustained a dislocation. Older age (ß = 0.316, P = .003) and male sex (ß = 5.532, P = .025) were predictive of tear size, and older age (ß = 0.229, P = .011) and biceps avulsion (ß = 8.822, P = .012) were predictive of tear retraction. CONCLUSIONS: Acute, traumatic RCTs have CSAs that are 5° smaller than those of degenerative tears, and the majority (60%) have CSAs that are below the threshold consistent with degenerative RCTs. The majority of traumatic tears (60%) involve the subscapularis. CLINICAL RELEVANCE: The study findings suggest that a traumatic tear is not simply the acute failure of a degenerative tendon and that it represents a distinct pathologic entity. These findings support current practice of treating traumatic RCTs differently than degenerative RCTs.

Grit Score is Predictive of Increased Risk for Opioid Prescription Refill Following Primary Arthroscopic Rotator Cuff Repair.

The grit score is used to measure passion and perseverance for long-term goals. We hypothesized that higher grit scores would predict improved 90-day outcomes and reduced opioid requirements after primary arthroscopic rotator cuff repair (RCR). Included were 103 patients. The median grit score was 3.9 (2.2-5.0). There was no statistically significant association between grit and morphine milligram equivalents prescribed or patient-reported pain control. Higher grit score was associated with a significant reduction in opioid prescription refill at 6 weeks, though this association was not seen at 2 or 12 weeks. The odds of requiring opioid medication 6 weeks after RCR increased 3.5 times per each 1.0 unit decrease in grit score. Patients with higher levels of grit, especially a score over 4.0, have a less difficult postoperative course after RCR. The grit score may help identify patients who are at increased risk for prolonged opioid use after RCR. (Journal of Surgical Orthopaedic Advances 32(3):177-181, 2023).

Delay in Knee MRI Scan Completion Since Implementation of the Affordable Care Act:: A Retrospective Cohort Study.

INTRODUCTION: The most impactful resolutions of the Patient Protection and Affordable Care Act (ACA) took effect on January 1, 2014. The clinical and economic effects are widely experienced by orthopaedic surgeons, but are not well quantified. We proposed to evaluate the effect of the ACA on the timing of MRI for knee pathology before and after implementation of the legislation. METHODS: We conducted a retrospective analysis of all knee MRIs done at our institution from 2011 to 2016 (3 years before and after ACA implementation). The MRI completion time was calculated by comparing the dates of initial clinical evaluation and MRI completion. The groups were subdivided based on insurance payer status (Medicare, Medicaid, and commercial payers). The cohorts were compared to determine differences in average completion time and completion rates at time intervals from initial clinic visit before and after ACA implementation. RESULTS: MRI scans of 5,543 knees were included, 3,157 (57%) before ACA implementation and 2,386 (43%) after. There was a 5.6% increase in Medicaid cohort representation after ACA implementation. Patients waited 14 days longer for MRIs after ACA implementation (116 versus 102 days). There were increased completion times for patients in the commercial payer (113 versus 100 days) and Medicaid (131 versus 96 days) groups. Fewer patients had received MRI after ACA implementation within 2, 6, and 12 weeks of their initial clinic visits. DISCUSSION: The time between initial clinical evaluation and MRI scan completion for knee pathology markedly increased after ACA implementation, particularly in the commercial payer and Medicaid cohorts. Additional studies are needed to determine the effect of longer wait times on patient satisfaction, delayed treatment, and increased morbidity. As healthcare policy changes continue, their effects on orthopaedic patients and providers should be closely scrutinized. LEVEL OF EVIDENCE: Level III-Retrospective cohort study.

Opioid-sparing pain management protocol after shoulder arthroplasty results in less opioid consumption and higher satisfaction: a prospective, randomized controlled trial.

BACKGROUND: The opioid epidemic has become a central focus in health care. In an effort to reduce opioid use, orthopedic surgeons use multimodal strategies to control postoperative pain. However, no clear consensus exists on ideal pain management strategies after shoulder arthroplasty, and most protocols are opioid-driven. This study sought to determine if patients undergoing shoulder arthroplasty using a postoperative opioid-sparing pain-control regimen would have equivalent pain scores and satisfaction as patients using a traditional opioid-based regimen. METHODS: Patients undergoing primary anatomic or reverse total shoulder arthroplasty were prospectively enrolled and randomized into an opioid-sparing (OS) or a traditional opioid-based (OB) postoperative pain protocol. Both groups received opioid education, periarticular injection with liposomal bupivacaine, and preoperative and postoperative multimodal management (acetaminophen, celecoxib, and gabapentin). The OB group was discharged with 40 oxycodone tablets and standard icing, whereas the OS group received ketorolac during admission, continuous cryotherapy, and discharged with 10 oxycodone tablets for rescue. Patients were queried regarding levels of pain and opioid consumption at days 1-7 and at 2, 6, and 12 weeks postoperatively. Patient satisfaction was recorded at 1, 2, 6, and 12 weeks. Range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) scores were assessed preoperatively and at 12 weeks postoperatively. Complications, readmissions, and reoperations were recorded. RESULTS: In 78 patients, no difference in VAS pain scores were seen at any time between groups. The OS group consumed less oral morphine equivalents (OME) from inpatient hospitalization to 12 weeks postoperatively (P < .05). Total OME consumption was reduced by 213% for the OS vs. the OB group (112 vs. 239; P < .0001). The OS group consumed fewer opioid pills at all time points (P < .05). A 395% reduction in number of opioid pills consumed in the first 12 weeks postoperatively was seen in the OS vs. the OB group (4.3 vs. 17.0; P < .0001). Significantly more patients in the OS group discontinued opioids by 2 weeks postoperatively (86.1% vs. 58.5%; P = .011), and 94.4% in the OS group discontinued opioids by 6 weeks postoperatively. The OS group was more satisfied with pain management at 1 and 6 weeks (P = .05). No difference in ROM, ASES or SANE scores, complications, readmissions, or reoperations were seen between groups. CONCLUSIONS: This study demonstrated a nearly 4-fold reduction in opioid pain pill consumption and earlier cessation of opioids with an OS pain management protocol. Patients also reported higher satisfaction with this pain management strategy.

Frozen Shoulder Manipulation with the FEAR Technique: A Retrospective Case Series with Minimum Two-Year Follow-up.

Conservative treatment of adhesive capsulitis fails in up to 30% of patients. Manipulation under anesthesia (MUA) has been shown to be safe and effective, although complications (iatrogenic fracture, glenohumeral dislocation, rotator cuff tears, nerve injuries) have been reported. This study details a novel technique, FEAR (Forward elevation, Extension, Adduction/abduction, and internal and external Rotation), and its results. Medical records review identified 100 patients with a diagnosis of adhesive capsulitis who had at least 6 weeks of physical therapy, with or without corticosteroid injection, with persistence of pain and loss of motion loss. An Institutional Review Board approved phone survey obtained Single Assessment Numeric Evaluation (SANE) scores, visual analog scale (VAS) scores, functional scores, and range of motion, with 43 available for survey. At average 5-year follow-up, 81% had excellent (≥ 90) scores and 77% were pain-free. Patients with diabetes and male patients had significantly lower SANE scores at follow-up. (Journal of Surgical Orthopaedic Advances 31(2):096-099, 2022).

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center.

BACKGROUND: A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone. METHODS: Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone. RESULTS: Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001). CONCLUSION: Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

Remplissage for Anterior Shoulder Instability: History, Indications, and Outcomes.

Remplissage is a nonanatomic capsulotenodesis of the infraspinatus tendon used to fill engaging or "off-track" Hill-Sachs lesions in patients at high risk of recurrent instability with isolated Bankart repair. Indications for remplissage are expanding, as the importance of subcritical bone loss and the glenoid track on patient outcomes and recurrence rates continues to be investigated. Remplissage is also suggested in patients at high risk of recurrent instability following isolated anterior labral repair, such as collision and contact athletes with Hill-Sachs lesions that have not reached the threshold of "off track." Multiple arthroscopic remplissage techniques exist including, more recently, knotless techniques.

Effect of deltoid volume on range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions.

BACKGROUND: Deltoid muscle function is paramount to the success of reverse total shoulder arthroplasty. The purpose of this study was to investigate the role of deltoid volume on shoulder range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions. METHODS: Retrospective review of records identified 107 patients who met inclusion criteria. The rotator cuff integrity was evaluated by two musculoskeletal-trained radiologists. Volumetric deltoid measurements were calculated from preoperative computed tomography or magnetic resonance imaging scans. Satisfactory outcomes were defined as forward elevation of at least 135°, external rotation of at least 35°, and American Shoulder and Elbow Surgeons and Single Assessment Numerical Evaluation scores of at least 70. RESULTS: Mean total deltoid muscle volume was significantly higher in patients with satisfactory forward elevation (57.8 ± 18.1 cm³) versus unsatisfactory forward elevation (48.6 ± 19.5 cm³) (p = 0.013). When separated by rotator cuff integrity, total deltoid volume was significantly higher (p = 0.030) in patients who achieved satisfactory forward elevation in the rotator cuff-deficient group but not the rotator cuff-intact group (p = 0.533). DISCUSSION: Preoperative deltoid volume directly correlated with achieving satisfactory forward elevation after reverse total shoulder arthroplasty in rotator cuff-deficient conditions and may be one factor in determining the ability to achieve satisfactory outcomes in the rotator cuff-deficient patient.

Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review.

INTRODUCTION: Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts. METHODS: The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05. RESULTS: Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use. DISCUSSION: Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA. LEVEL OF EVIDENCE: Level IV; systematic review.