Technological innovations in shoulder replacement: current concepts and the future of robotics in total shoulder arthroplasty.

BACKGROUND: Total shoulder arthroplasty (TSA) has been rapidly evolving over the last several decades, with innovative technological strategies being investigated and developed in order to achieve optimal component precision and joint alignment and stability, preserve implant longevity, and improve patient outcomes. Future advancements such as robotic-assisted surgeries, augmented reality, artificial intelligence, patient-specific instrumentation (PSI) and other peri- and preoperative planning tools will continue to revolutionize TSA. Robotic-assisted arthroplasty is a novel and increasingly popular alternative to the conventional arthroplasty procedure in the hip and knee but has not yet been investigated in the shoulder. Therefore, the purpose of this study was to conduct a narrative review of the literature on the evolution and projected trends of technological advances and robotic assistance in total shoulder arthroplasty. METHODS: A narrative synthesis method was employed for this review, rather than a meta-analysis or systematic review of the literature. This decision was based on 2 primary factors: (1) the lack of eligible, peer-reviewed studies with high-quality level of evidence available for review on robotic-assisted shoulder arthroplasty, and (2) a narrative review allows for a broader scope of content analysis, including a comprehensive review of all technological advances-including robotics-within the field of TSA. A general literature search was performed using PubMed, Embase, and Cochrane Library databases. These databases were queried by 2 independent reviewers from database inception through November 11, 2022, for all articles investigating the role of robotics and technology assistance in total shoulder arthroplasty. Inclusion criteria included studies describing "shoulder arthroplasty" and "robotics." RESULTS: After exclusion criteria were applied, 4 studies on robotic-assisted TSA were described in the review. Given the novelty of this technology and limited data on robotics in TSA, these studies consisted of a literature review, nonvalidated experimental biomechanical studies in sawbones models, and preclinical proof-of-concept cadaveric studies using prototype robotic technology primarily in conjunction with PSI. The remaining studies described the technological advancements in TSA, including PSI, computer-assisted navigation, artificial intelligence, machine learning, and virtual, augmented, and mixed reality. Although not yet commercially available, robotic-assisted TSA confers the theoretical advantages of precise humeral head cuts for restoration of proximal humerus anatomy, more accurate glenoid preparation, and improved soft-tissue assessment in limited early studies. CONCLUSION: The evidence for the use of robotics in total hip arthroplasty and total knee arthroplasty demonstrates improved component accuracy, more precise radiographic measurements, and improved early/mid-term patient-reported and functional outcomes. Although no such data currently exist for shoulder arthroplasty given that the technology has not yet been commercialized, the lessons learned from robotic hip and knee surgery in conjunction with its rapid adoption suggests robotic-assisted TSA is on the horizon of innovation. By achieving a better understanding of the past, present, and future innovations in TSA through this narrative review, orthopedic surgeons can be better prepared for future applications.

Epidemiology of Sports-Related Clavicle Fractures in the United States: Injuries From 2015 to 2019.

Background: Clavicle fractures are common orthopaedic injuries that frequently occur during sports and recreational activity. Purpose: To (1) determine the incidence rate of sports-related clavicle fractures among patients evaluated in emergency departments in the United States over a 5-year period, (2) determine the most common sports and risks associated with clavicle fractures, and (3) update the literature by comparing past and present injury trends. Study Design: Descriptive epidemiology study. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried for patients evaluated with clavicle fractures in US emergency departments from 2015 to 2019. The authors evaluated the data by age, sex, race, and sport/recreational activity. Injuries were characterized based on sports-specific mechanism of injury. Using the NEISS weighted multiplier, the authors estimated annual incidence rates based on US Census data. Contingency table comparisons of categorical variables (ie, age groups vs sex distributions) were analyzed using either chi-square or Fisher exact tests as appropriate for the population size, while continuous variable comparisons were performed using 1-way analysis of variance statistical testing. Results: A total of 2386 athletic-related clavicle fractures were evaluated at participating emergency departments, translating to 304,211 clavicle fractures, with an annual per-year injury rate of 18.72 clavicle fractures per 100,000 persons at risk (95% CI, 15.28-23.67). Male athletes had disproportionately higher injury rates than female athletes (P < .001) for every year of the study and demonstrated a higher incidence of fractures compared with female athletes (injury proportion ratio, 5.54). Patients aged 10 to 19 years accounted for the highest overall incidence of injury (64.5%). The annual incidence rate of athletic-related clavicle fractures was not significantly different during the study period (P = .24). The most common mechanisms of injury were participation in football (26.87%), soccer (15.76%), snowboarding (5.03%), bicycling (3.77%), wrestling (3.65%), and snow skiing (3.52%). Conclusion: Study findings indicated that clavicle fractures sustained during sports and recreational activity disproportionately affect male athletes. Adolescent populations (10-19 years of age) had the highest overall incidence of injury, and the most common activities associated with clavicle fractures were football and soccer.

Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty: a survey-based study.

BACKGROUND: Outpatient (OP) total shoulder arthroplasty (TSA) with same-day discharge can now be performed safely in appropriately selected patients. Patient knowledge and perspectives regarding OP TSA are yet unknown and such information may inform surgeon decision-making and provide a framework for addressing patient concerns. The goal of this study was to understand and quantify patient knowledge of and concerns for OP TSA, with a working hypothesis that majority of patients are unaware of OP TSA as a realistic option and that their primary concern would be postoperative pain control. METHODS: This was a retrospective cohort study at a tertiary care academic medical center including patients who underwent anatomic or reverse shoulder arthroplasty and completed an OP TSA expectations questionnaire/survey. This survey was provided preoperatively and included demographic factors, self-rated health evaluation, and perioperative expectations. Surveys evaluated whether patients undergoing TSA had any prior awareness of OP TSA and evaluated their primary concern with same-day discharge. Secondary questions included an assessment of patient expectations of outcomes of outpatient vs. inpatient surgery as well as their expected length of inpatient stay. RESULTS: A total of 122 patients who underwent anatomic and reverse shoulder arthroplasty completed the questionnaire and comprised the study cohort. Fifty-two (42.6%) of the patients were unaware that OP TSA was an option, and 26 (50%) of these were comfortable with the idea of OP TSA. Comfort with OP TSA was significantly associated with higher subjective patient-reported health status. Fifty-eight patients (47.5%) expected that following TSA they would require <24 hours of in-hospital postoperative care. The primary concern for patients considering OP TSA was postoperative pain control, endorsed by 44.3% of patients, compared with 13.1% of patients stating this would be their primary concern if admitted as an inpatient postoperatively. Pain control being a primary concern was significantly different between those considering outpatient vs. inpatient TSA. Most patients anticipated that OP shoulder arthroplasty would lead to a better (36%) or comparable (53%) outcome, whereas only 11% had concerns that it would lead to a worse outcome. CONCLUSION: Expanding OP TSA crucially depends on awareness and education. Perceived ability to control pain is an important concern. Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy.

Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty.

BACKGROUND: Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA. METHODS: This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization. RESULTS: The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P < .001) and 36 hours (3 vs. 2, P < .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P < .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038). CONCLUSIONS: LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.