Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report.

CASE: A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal. CONCLUSION: Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

Elbow Arthroscopy: Essential Principles of Positioning, Anatomy, and Portal Placement.

Elbow arthroscopy is an important surgical technique for the treatment of various elbow pathologies. Range of indications for elbow arthroscopy include, but are not limited to, diagnostic evaluation, removal of loose bodies, synovectomy, contracture releases, lateral epicondylitis treatment, and adjunct use for fracture reduction. Surgeons' understanding of anatomy and portal placement is critical for successful treatment. This article reviews the relevant surgical anatomy, portal placement, patient positioning, surgical indications, and complications for this technique.

Post-operative Baseplate Radiographic Evaluation Using Routine pre-Operative CT.

Background: There is limited data evaluating post-operative component position and fixation in reverse shoulder arthroplasty (RSA). Therefore, the purpose of this study was to evaluate baseplate position and fixation using routine pre-operative CT and post-operative radiographs. Methods: A retrospective analysis of a series consecutive patient who underwent primary RSA was performed. Pre-operative and post-operative glenoid retroversion and inclination were measured using radiographs aligned with projection silhouettes of 3D scapula models in Mimics software. Baseplate retroversion and inclination were measured followed by evaluating for the presence of radiolucent lines (RLLs). Results: Twenty-four patients met inclusion criteria. The average age was 73.4 ± 10.7 years (range, 45-89 years). Radiographic follow-up was 3.4 ± 1.3 years. Post-operative glenoid baseplate retroversion was 2 ± 10 degrees (range, 30 to -9). Post-operative glenoid baseplate inclination was 3.8 ± 9.1 (range, -13 to 19). Five (21%) RSAs had baseplate retroversion >10 degrees. Follow-up radiographs revealed no RLLs around the baseplate, central post, or peripheral screws in any patient. Conclusions: Pre-operative CT imaging enabled evaluation of baseplate component placement and fixation on post-operative radiographs. Baseplate version was within 10 degrees of neutral in 79% (19/24) of patients. No RLLs or loss of fixation were found in any cases. Level of Evidence: Level IV: Diagnostic Study.

Comparing Skill Acquisition and Validity of Immersive Virtual Reality with Cadaver Laboratory Sessions in Training for Reverse Total Shoulder Arthroplasty.

Immersive virtual reality (iVR) allows surgical trainees to practice skills without risking harm to patients or the need for cadaveric training resources. However, iVR has never been directly compared with cadaver training, the longtime gold standard for surgical skill training. We aimed to compare skill acquisition using cadaver laboratory and iVR training methods for augmented baseplate implantation during reverse total shoulder arthroplasty (rTSA). Methods: In a randomized controlled trial, junior orthopaedic surgery residents were assigned to a 1-hour training with either iVR or a cadaveric laboratory session with shoulder specimens. Before training, all participants viewed an overview lecture and technique video demonstrating key steps of augmented baseplate implantation for rTSA. Participants were assessed by a blinded evaluator using validated competency checklists during cadaveric glenoid baseplate implantation. Continuous and categorial variables were analyzed using the 2-sample t test and Fisher exact test. Results: Fourteen junior residents (3 incoming matched postgraduate year [PGY1], 6 PGY1s, 1 PGY2, and 4 PGY3s) were randomized to training with either iVR (n = 6) or cadaver laboratory (n = 8). There were no significant differences in demographic data, previous experience with rTSA, or previous use of iVR (p > 0.05). There were no significant difference in total Objective Structured Assessment of Technical Skill score (91.2% [15.2] vs. 93.25% [6.32], -0.1406 to 0.1823, p = 0.763), Global Rating Scale score (4.708 [0.459] vs. 4.609 [0.465], -0.647 to 0.450, p = 0.699), or time to completion (546 seconds [158] vs. 591 seconds [192], -176.3 to 266.8, p = 0.655) in cadaveric glenoid baseplate implantation. Average cost of iVR hardware and a 1-year software license was $4,900, and average cost of a single cadaver laboratory was $1,268.20 per resident. Conclusions: Among junior orthopaedic residents, there is similar skill acquisition when training with either cadaver laboratory or iVR. Although additional research into this field is needed, iVR may provide an important and cost-effective tool in surgical education. Clinical Relevance: Emerging simulation and iVR technology simulation in surgical training programs can increase access to effective and high-level surgical training across the globe and improve quality of care.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched - Pair Analysis.

Background: There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case. Methods: A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case. Results: A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction. Discussion: Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.

Comparison of glenoid bone grafting vs. augmented glenoid baseplates in reverse shoulder arthroplasty: a systematic review.

BACKGROUND: Management of bone loss and glenoid deformity can present a significant challenge to surgeons. The purpose of this review was to compare outcomes of reverse shoulder arthroplasty (RSA) using either bone graft or augmented baseplates for the management of glenoid bone loss and deformity. METHODS: A comprehensive search of MEDLINE, Embase, and Cochrane indices was performed for studies reporting clinical outcomes following primary RSA with bone grafting or use of augmented baseplates. Pooled and frequency-weighted means, standard deviations, and ranges were calculated and reported for comparison. RESULTS: Overall, 19 studies and 652 patients with bone grafting (n = 401) and augmented baseplates (n = 251) were included in the study. Mean patient age and gender were 70.3 ± 3.1 years and 47% female in the bone grafting group and 72.9 ± 3.7 years and 59.0% female in the augmented baseplate group. Mean follow-up for the augmented baseplate group was 23.1 ± 8.2 months and 29.5 ± 10.1 months for the bone grafting group. Overall complication and revision rates were 11.7% and 4.5% for the bone grafting group and 11.8% and 3.7% for the augmented baseplate group. Range of motion as well as patient-reported and functional outcome scores were similar between both techniques. Infections, component loosening, and notching were 1.9%, 3.6%, and 24.6% in the bone grafting group and 0.7%, 1.6%, and 4.7% in the augmented baseplate group. CONCLUSIONS: Glenoid bone grafting and augmented baseplates are effective treatment options for the management of bone loss and glenoid deformity. Both treatments improve overall clinical outcomes with relatively low complication rates and revision rates.

Does the timing of tenotomy during biceps tenodesis affect the incidence of Popeye deformity and clinical outcome? An analysis of short-term follow-up of 2 techniques.

BACKGROUND: There are multiple techniques that attempt to maintain anatomic length-tension relationship during biceps tenodesis. However, no direct comparison has been performed with respect to the timing of biceps tenotomy during biceps tenodesis. This study aims to assess the incidence of Popeye deformity and clinical outcomes of 2 all-arthroscopic techniques for biceps tenodesis based on timing of the biceps tenotomy. METHODS: A consecutive series of patients undergoing arthroscopic biceps tenodesis with concomitant rotator cuff tears were enrolled from 2019 to 2021. Biceps tenodesis performed after tenotomy formed the first cohort (group 1). The other cohort had biceps tenodesis performed prior to biceps tenotomy (group 2). Postoperative anterior arm pain, biceps muscle spasms, and patient perceptions of the appearance of the bicep muscle were assessed. In addition, patient-reported outcomes (PROs) were collected at 3 months and minimum 6 months postoperatively. RESULTS: A total of 71 patients were eligible for participation and 62 patients (53% female, age 58.7 ± 9.0 years) were enrolled (n = 33 in group 1, and n = 29 in group 2). There were no differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. At 3-month follow-up, Veterans RAND 12-Item Health Survey (VR-12) physical health summary scores were significantly improved in group 2 (44.8 ± 9.7) compared with group 1 (34.1 ± 3.4) (P = .03). In addition, patients in group 2 experienced significantly less pain in their anterior arm than patients in group 1 (19% vs. 33%, P = .02). There were no differences in biceps muscle spasm (3.4% vs. 5.2%, P = .21) and no other differences in PROs between groups. Final follow-up averaged 11.6 ± 3.3 months in group 1 and 11.8 ± 5.5 months in group 2. There were no significant differences in patient-perceived biceps Popeye deformity between group 1 (12.1%) and group 2 (0%) (P = .652). Furthermore, there were no differences in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, EuroQol-5 Dimension, Patient-Reported Outcomes Measurement Information System Global Health (PROMIS 10) physical health, PROMIS 10 depression, VR-12 physical health summary, and Single Assessment Numeric Evaluation scores between the 2 technique groups. CONCLUSION: Patients with tenotomy performed after tenodesis had better VR-12 physical health summary scores and less arm pain than patients with tenotomy performed before tenodesis at 3-month follow-up. However, there were no differences in any outcome at final follow-up of nearly 1-year. In addition, there were no differences in perceived Popeye deformity between groups at any time period.

Mortality Rate Increase in Elderly Patients With Hip Fractures Presenting During the COVID-19 Pandemic to a Hospital in the United States Epicenter: Minimum 30-day Follow Up Comparative Study.

The purpose of this study was to compare mortality and complication rates among geriatric patients who sustained a hip fracture before the coronavirus disease (COVID-19) pandemic began to those who presented during the peak of the pandemic. Patients greater than or equal to 50 years of age who presented with a diagnosis of hip fracture from March 16, 2020 to May 1, 2020 were compared with a historical control group who presented between December 1, 2019 and January 16, 2020. Minimum follow up was 30 days. The primary outcome was a 30-day mortality rate. Thirty-day mortality was significantly different between groups, with no deaths of 24 patients in the pre-COVID-19 cohort versus six deaths of 23 patients (26.1%) in the COVID-19 cohort (chi-squared test, p-value = 0.02). The study concluded that the COVID-19 pandemic increased mortality risk for geriatric hip fracture patients. (Journal of Surgical Orthopaedic Advances 32(4):232-237, 2023).

Venous thromboembolism prophylaxis with low molecular weight heparin versus unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures.

Background: The objective of this study was to compare inpatient mortality rates for patients with operatively treated closed femoral shaft fractures (AO/OTA 32 A-C) who received venous thromboembolism (VTE) prophylaxis with either low molecular weight heparin (LMWH) or unfractionated heparin. Methods: This was a retrospective cohort study of a national database of patients presenting to Level I through IV trauma centers in the United States. All patients ≥18 years of age who sustained an operatively treated closed femoral shaft fracture were included. The primary outcome of inpatient mortality was compared between two groups: those who received LMWH or unfractionated heparin for VTE prophylaxis. Secondary outcomes were complications including VTE and bleeding events. Groups were compared using a multivariate regression model. Results: There were 2058 patients included in the study. Patients who received VTE prophylaxis with LMWH had lower odds of inpatient mortality compared to patients who received VTE prophylaxis with unfractionated heparin (OR 0.19; 95% CI 0.05 to 0.68, p = 0.011). Conclusions: VTE prophylaxis with LMWH is associated with lower inpatient mortality compared to VTE prophylaxis with unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures. To our knowledge this is the first study to report these associations for a specific subset of orthopedic trauma patients.

Incidental Pulmonary Nodules Found on Shoulder Arthroplasty Preoperative CT Scans.

With current emphasis on preoperative templating of anatomical and reverse shoulder arthroplasty (aTSA and rTSA, respectively), patients often receive thin slice (<1.0 mm) computerized tomography (CT) scans of the operative shoulder, which includes about two-thirds of the ipsilateral lung. The purpose of this study is to evaluate the prevalence and management of incidentally detected pulmonary nodules on preoperative CT scans for shoulder arthroplasty. In this single-center retrospective study, we queried records of aTSA and rTSA patients from 2015 to 2020 who received preoperative CT imaging of the shoulder. Compared to patients with negative CT findings, there were significantly more females (63.8% vs. 46.4%; P = .011), COPD (13.0% vs. 4.7%; P = .015), and asthma (18.8% vs. 6.9%; P = .003) among the patients with incidental nodules on CT. Binary logistic regression confirmed that female sex (odds ratio = 2.00; 95% CI = 1.04 to 3.88; P = .037), COPD history (OR = 3.02; 95% CI = 1.05 to 8.65; P = .040), and asthma history (OR = 3.17; 95% CI = 1.30 to 7.77; P = .011) were significantly associated with an incidental nodule finding. Incidental pulmonary nodules found on shoulder arthroplasty preoperative CT scans are often low risk in size with low risk of malignancy, and do not require further workup. This study may provide guidance to orthopedic surgeons on how to manage patients with incidental pulmonary nodules to increase chances of early cancer detection, avoid unnecessary referrals, reduce potentially harmful radiation exposure of serial CT scans, and improve cost efficiency.

Early career opportunities and practice characteristics of recent graduates of shoulder and elbow fellowship programs.

BACKGROUND: There exists anecdotal evidence that influential faculty members actively dissuade orthopedic surgery residents from pursuing a fellowship in shoulder and elbow due to a perceived lack of availability of jobs following graduation. The aims of the present study are to evaluate whether this perception is true by characterizing the early career opportunities and practice characteristics of recent graduates of shoulder and elbow fellowship programs through a survey of graduates of the past 5 years. METHODS: An anonymous 39-question survey was designed and approved by the leadership of the American Shoulder and Elbow Surgeons (ASES). The survey was distributed via electronic mail to the fellowship directors and coordinators of the 31 ASES-recognized shoulder and elbow fellowship programs. The fellowship directors and coordinators then sent the survey to the shoulder and elbow fellowship graduates of the last 5 years (2016-2020). Following a total of 4 emails, the survey closed after 8 weeks, and descriptive statistical analysis was performed. RESULTS: Seventy-six of 171 (44.4%) fellows responded. In total, 89.5% were very or somewhat satisfied with their fellowship experience, and 90.8% would pursue a shoulder and elbow fellowship again. Notably, 100% of shoulder and elbow fellowship graduates surveyed in the past 5 years have secured employment. The average number of total orthopedic and shoulder and elbow cases performed annually was 296.7 (SD 141.3) and 173.9 (SD 120.2), respectively. In addition, 62.7% and 89% of respondents were very or somewhat satisfied with the volume and surgical complexity of shoulder and elbow cases, respectively. For the fellows that believed their case experience to be inadequate, the most common reasons were competition from other practices (66.0%) and inadequate patient volume (59.6%). CONCLUSION: Recent graduates of the ASES-recognized shoulder and elbow fellowship programs demonstrate a high level of satisfaction with the fellowship and their subspeciality selection. The majority of fellows believed that completing a shoulder and elbow fellowship enhanced their job opportunities. Altogether, there are ample job opportunities and high satisfaction with the volume and complexity of cases as an early career shoulder and elbow surgeon.

Disparities in Telemedicine Utilization During COVID-19 Pandemic: Analysis of Demographic Data from a Large Academic Orthopaedic Practice.

Background: The coronavirus-19 (COVID-19) pandemic has prompted a shift in health-care provision toward implementation of telemedicine. This study investigated demographic information on orthopaedic telemedicine utilization at a single academic orthopaedic institution in an effort to identify factors associated with telemedicine usage. Methods: Demographic and appointment data were collected from the electronic medical record during equivalent time periods prior to the onset of the COVID pandemic (pre-COVID) and during the COVID pandemic (peri-COVID). Multivariate analyses were performed to identify demographic and socioeconomic correlates of telemedicine utilization. Results: There was a significant increase in telemedicine visits between the eras of study, with significant differences in telemedicine usage in association with age, sex, marital status, English as the primary language, and insurance type (p < 0.001). Multivariate analyses found American Indian/Alaska Native (adjusted odds ratio [aOR] = 0.487, p = 0.004), Black/African American (aOR = 0.622, p < 0.001), Native Hawaiian/other Pacific Islander (aOR = 0.676, p = 0.003), and Asian (aOR = 0.731, p < 0.001) race to be significantly associated with decreased telemedicine usage. Additionally, male sex (aOR = 0.878, p < 0.001) and a non-commercial insurance plan (p < 0.001) were significantly associated with decreased telemedicine usage. Conclusions: Non-White race, non-commercial insurance plans, and male sex were associated with decreased telemedicine utilization. Further investigation is needed to characterize and better identify underlying factors contributing to disparities in telemedicine access and utilization.

Comparison of Glenoid Bone Grafting versus Augmented Glenoid Baseplates in Reverse Shoulder Arthroplasty: A Systematic Review.

BACKGROUND: Management of bone loss and glenoid deformity can present a significant challenge to surgeons. The purpose of this review was to compare outcomes of reverse shoulder arthroplasty (RSA) using either bone graft or augmented baseplates for the management of glenoid bone loss and deformity. METHODS: A comprehensive search of MEDLINE, Embase, Cochrane indices was performed for studies reporting clinical outcomes following primary RSA with bone grafting or use of augmented baseplates. Pooled and frequency-weighted means were calculated where applicable. Between-group comparison was also performed. RESULTS: Overall, 19 studies and 652 patients were included in the study. There were no significant differences in age or gender between the bone grafting (70.3 years; 47.8% female) and augmented baseplate (72.9 years; 59.0% female) groups (p=0.166; p=0.659). Overall complication and revision rates were similar for reverse shoulder arthroplasty (RSA) using either bone graft (11.7% complication rate; 4.5% revision rate) or augmented baseplates (11.8% complication rate; 3.7% revision rate) for the management of glenoid bone loss and deformity (p=0.968; p=0.562). Furthermore, range of motion as well as patient-reported and functional outcome scores were similar between both techniques. However, infections (0.7% augmented baseplate; 1.9% bone grafting) and notching (4.7% augmented baseplate; 24.6% bone grafting) were found to be more common in the bone grafting group (p=0.012; p=0.018). CONCLUSIONS: Glenoid bone grafting and augmented baseplates have similar overall clinical outcomes, complication rates, and revision rates. However, there were some significant differences between groups with respect to notching and infections which deserve consideration and further exploration.

Characterization of ASES score pain and functional improvement after anatomic total shoulder arthroplasty: a patient-centered perspective.

BACKGROUND: Interpretation of anchor-based clinical differences in the context of pain and functional change remains undefined. The purpose of this study was to characterize American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores for patients after anatomic total shoulder arthroplasty with minimum 1 year of follow-up in terms of pain and change in each functional element on the ASES. METHODS: We performed a retrospective study of a prospective institutional patient database of primary anatomic total shoulder arthroplasties from 2017-2020 with baseline and 1-year postoperative ASES scores. Three clinical outcome groups were established using an anchor-based global rating of change assessment: minimal clinically important difference (MCID), moderate clinical benefit (MCB), and substantial clinical benefit (SCB). Pain and functional outcomes in each group where then characterized and compared. RESULTS: A total of 67 patients were analyzed in terms of demographics and clinical outcomes. Two-thirds (65%) of patients achieved the SCB, 24% achieved the MCB, and 10% achieved the MCID. Washing, reaching for a shelf, and throwing were the most common functional deficits experienced preoperatively and accounted for the largest improvement in function postoperatively. Patients in the MCID group had higher preoperative visual analog scale (VAS) pain scores (7.1 ± 3.0) than the MCB (5.8 ± 2.5) or SCB (5.8 ± 2.2) groups (P = .0612). The MCID group had the least amount of preoperative functional deficits when compared to the MCB and SCB groups (P = .041). Postoperative VAS pain scores improved by 5.1 in the SCB, 3.6 in the MCB, and 3.7 in the MCID groups. Functional change in each element of the ASES improved by 1.4/4 in the SCB, followed by 0.9/4 in the MCB group and 0.05/4 in the MCID group (P < .001). CONCLUSION: The MCID group had higher preoperative pain scores and the least amount of preoperative functional deficits when compared to the MCB and SCB groups. The MCID was realized through pain improvement only, whereas the MCB and SCB consisted of meaningful improvements in pain and function.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial.

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment.

BACKGROUND: Many in-season athletes choose to delay or avoid surgery in order to continue playing and avoid downtime such as missed games or seasons. PURPOSE: To learn about the attitudes toward the injury and treatment of in-season shoulder instability in competitive athletes who have suffered a shoulder dislocation. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A study-specific questionnaire about athletes' perceptions of injury and treatment was administered to injured players. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). Mean scores and standard deviations were calculated, and between-group analyses with t tests were performed to compare the ASES and WOSI scores. The Mann-Whitney U test was used for analyses performed on the following groups: early operative versus nonoperative management; age <18 versus ≥18 years; first-time dislocators versus recurrent dislocators; self-reducing subluxations versus dislocations requiring assistance; and dominant arm affected versus nondominant arm. RESULTS: There were 45 patients included in this study (33 male, 12 female) with a mean age of 18 ± 2.8 years. Several sports were represented, with the most common being football, baseball, soccer, and rugby. In this study of in-season athletes with shoulder instability, 13 (28.9%) chose early surgery, 4 (8.9%) chose surgery at season's end, while 28 (62.2%) chose physical therapy followed by a wait-and-see approach, with 13 (46.4%) of these patients ultimately requiring surgery. Athletes who chose nonoperative treatment were statistically more likely to believe that their shoulder would heal on its own (P < .001) or with physical therapy (P < .025); they were also more likely to agree that they would rather stop sports than undergo surgery (P < .04). Athletes with worse ASES and WOSI scores at injury were more likely to choose surgery (P < .03 and P < .05, respectively). Athletes with >1 dislocation were less likely to believe that the shoulder would heal without surgery (P < .025). Most athletes agreed that seasonal timing and recruitment prospects were an important factor in their decision in favor of surgery (P < .038), and most agreed that their doctor influenced their ultimate treatment decision (P < .006). Most athletes also agreed that a repeat dislocation would cause further injury to the shoulder. CONCLUSION: Treatment decisions were most strongly related to the athletes' perceptions of injury severity and the influence of the treating surgeon.

Using machine learning methods to predict nonhome discharge after elective total shoulder arthroplasty.

BACKGROUND: Machine learning has shown potential in accurately predicting outcomes after orthopedic surgery, thereby allowing for improved patient selection, risk stratification, and preoperative planning. This study sought to develop machine learning models to predict nonhome discharge after total shoulder arthroplasty (TSA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective TSA from 2012 to 2018. Boosted decision tree and artificial neural networks (ANN) machine learning models were developed to predict non-home discharge and 30-day postoperative complications. Model performance was measured using the area under the receiver operating characteristic curve (AUC) and overall accuracy (%). Multivariate binary logistic regression analyses were used to identify variables that were significantly associated with the predicted outcomes. RESULTS: There were 21,544 elective TSA cases identified in the National Surgical Quality Improvement Program registry from 2012 to 2018 that met inclusion criteria. Multivariate logistic regression identified several variables associated with increased risk of nonhome discharge including female sex (odds ratio [OR] = 2.83; 95% confidence interval [CI] = 2.53-3.17; P < .001), age older than 70 years (OR = 3.19; 95% CI = 2.86-3.57; P < .001), American Society of Anesthesiologists classification 3 or greater (OR = 2.70; 95% CI = 2.41-2.03; P < .001), prolonged operative time (OR = 1.38; 95% CI = 1.20-1.58; P < .001), as well as history of diabetes (OR = 1.56; 95% CI = 1.38-1.75; P < .001), chronic obstructive pulmonary disease (OR = 1.71; 95% CI = 1.46-2.01; P < .001), congestive heart failure (OR = 2.65; 95% CI = 1.72-4.01; P < .001), hypertension (OR = 1.35; 95% CI = 1.20-1.52; P = .004), dialysis (OR = 3.58; 95% CI = 2.01-6.39; P = .002), wound infection (OR = 5.67; 95% CI = 3.46-9.29; P < .001), steroid use (OR = 1.43; 95% CI = 1.18-1.74; P = .010), and bleeding disorder (OR = 1.84; 95% CI = 1.45-2.34; P < .001). The boosted decision tree model for predicting nonhome discharge had an AUC of 0.788 and an overall accuracy of 90.3%. The ANN model for predicting nonhome discharge had an AUC of 0.851 and an overall accuracy of 89.9%. For predicting the occurrence of 1 or more postoperative complications, the boosted decision tree model had an AUC of 0.795 and an overall accuracy of 95.5%. The ANN model yielded an AUC of 0.788 and an overall accuracy of 92.5%. CONCLUSIONS: Both the boosted decision tree and ANN models performed well in predicting nonhome discharge with similar overall accuracy, but the ANN had higher discriminative ability. Based on the findings of this study, machine learning has the potential to accurately predict nonhome discharge after elective TSA. Surgeons can use such tools to guide patient expectations and to improve preoperative discharge planning, with the ultimate goal of decreasing hospital length of stay and improving cost-efficiency.

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs. METHODS: A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response. RESULTS: Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation. CONCLUSION: This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

INTRODUCTION: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. METHODS: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. RESULTS: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). CONCLUSION: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

State Medical Cannabis Laws Associated With Reduction in Opioid Prescriptions by Orthopaedic Surgeons in Medicare Part D Cohort.

INTRODUCTION: Opioid prescriptions and abuse remain a significant national concern. Cannabinoids offer a potentially attractive nonopioid analgesic option for orthopaedic patients, and 32 US states have passed medical cannabis laws (MCLs), legalizing patient access to cannabinoids. We examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients between 2013 and 2017. METHODS: Using the Medicare Part D Prescription Drug Event database, we measured annual aggregate daily doses of all opioid medications (excluding buprenorphine) prescribed by orthopaedic surgeons in each US state (and DC), in addition to total daily doses of opioid medications by generic name (hydrocodone, oxycodone, fentanyl, morphine, methadone, and "other opioids"). We used adjusted linear regression models to examine associations between state-specific cannabis regulations (state MCL, MCL type-dispensary or home cultivation, and recreational cannabis legalization) and annual total daily doses of opioid medications (all opioids and opioid types, separately). RESULTS: State MCLs were associated with a statistically significant reduction in aggregate opioid prescribing of 144,000 daily doses (19.7% reduction) annually (95% confidence interval [CI], -0.535 to -0.024 million; P < 0.01). States with MCLs allowing access to in-state dispensaries had a statistically significant reduction in total opioid prescriptions of 96,000 daily doses (13.1%) annually (95% CI, -0.165 to -0.026 million; P < 0.01). Specifically, MCLs were associated with a statistically significant reduction of 72,000 daily doses of hydrocodone annually (95% CI, -0.164 to -0.019 million; P < 0.01). No significant association between recreational marijuana legalization and opioid prescribing was found. CONCLUSION: Orthopaedic surgeons are among the highest prescribers of opioids, highlighting the importance of providing nonopioid analgesic alternatives in efforts to reduce opioid use in the patient cohort. This study is the first to examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients. LEVEL OF EVIDENCE: Population-based ecological study.