Clinical and radiographic outcomes of shoulder hemiarthroplasty for patients with glenoid medialization.

BACKGROUND: Glenoid bone loss in shoulder arthroplasty is a difficult problem that is prone to complications because of challenges with achieving glenoid component fixation and stability. The purpose of this study was to evaluate the outcomes of primary shoulder hemiarthroplasty for patients with severe glenoid medialization precluding placement of a glenoid component. METHODS: This was a retrospective case series evaluating patients who underwent shoulder hemiarthroplasty for severe glenoid erosion and medialization between 2010 and 2020. Patients were evaluated via chart review and phone survey to determine if there were any reoperations at final follow-up and to obtain Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Preoperative and postoperative radiographs were evaluated and compared to determine glenoid morphology, version, medialization, acromiohumeral distance, and humeral offset. Final postoperative films were also evaluated for anterosuperior migration and signs of mechanical failure, including loosening or periprosthetic fracture. RESULTS: Overall, there were 28 patients during this period who underwent shoulder hemiarthroplasty for severe glenoid medialization. Eight patients were deceased at the time of the study, 2 were unable to complete surveys because of dementia, and 7 were lost to follow-up. The final cohort included 11 shoulders and 11 patients with a mean age of 71 ± 7.1 years and mean follow-up of 6.7 years (range 1.6-13.0 years). Mean postoperative SANE, ASES, and SST scores were 80.6 ± 17.6, 71.5 ± 29.3, and 7.6 ± 2.0, respectively. There were no reoperations or revision surgeries at final follow-up. Radiographic evaluation demonstrated severe glenoid medialization and decreased lateral humeral offset, which was unchanged postoperatively. There were 2 patients with signs of anterosuperior migration at final radiographic follow-up but no signs of implant failure. CONCLUSION: Shoulder hemiarthroplasty for severe medial glenoid bone loss provides modest clinical outcomes and low rates of reoperation at mid- to long-term follow-up and is an option worth considering in cases where placement of a glenoid component is challenging because of deficient bone stock and high risk for complications.

Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group.

BACKGROUND: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants. METHODS: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA. RESULTS: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001). CONCLUSION: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.

Comparison of total elbow arthroplasty complications between various surgical indications at 90-day and 1-year follow-up in 1600 elbows.

BACKGROUND: Total elbow arthroplasty (TEA) was traditionally a mainstay of treatment for patients with severe inflammatory arthritis. Recently, the indications for TEA have expanded, and TEA has grown into a versatile procedure that can be used to treat several pathologies of the elbow. The objective of this study was to compare complication rates between TEAs performed for rheumatoid arthritis (RA), fracture (FX), or osteoarthritis (degenerative joint disease [DJD]). METHODS: A retrospective analysis of the MUExtr data set of the PearlDiver national database was performed. International Classification of Diseases, Tenth Revision codes were used to identify patients who underwent TEA from 2010-2020 and to separate them into RA, FX, and DJD cohorts. Demographic characteristics, comorbidities, and hospital data were identified and compared using analysis of variance. Systemic complications at 90 days and surgical complications at both 90 days and 1 year were compared using multivariable logistic regression. Surgical complications included wound dehiscence, hematoma, deep infection, periprosthetic FX, stiffness, instability, triceps injury, nerve injury, and need for revision. RESULTS: We identified 1600 patients (DJD, 38.9%; FX, 48.8%; and RA, 12.3%). The majority of patients in all 3 cohorts were female patients, with the RA group having a significantly higher percentage of female patients than the FX and DJD groups (87.3% vs. 81.4% and 76.9%, respectively; P = .003). No significant differences in systemic complications and surgical complications were noted between all 3 groups at 90 days postoperatively. After controlling for patient factors, FX patients were more likely to have elbow stiffness (odds ratio, 1.53; P = .006) and less likely to have a triceps injury (odds ratio, 0.26; P < .001) at 1 year than were RA or DJD patients. CONCLUSION: The indications for TEA have expanded over the past 10 years, with nearly half of all cases being performed for FX. At 1 year postoperatively, TEAs performed for FX have a significantly lower rate of triceps injury and higher rate of elbow stiffness than TEAs performed for other indications. This finding is important to consider when preoperatively planning, as well as when discussing expected outcomes with patients prior to surgery, especially with the expanded incidence of TEA for FX being performed over the past decade.

Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group.

BACKGROUND: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status. METHODS: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis. RESULTS: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort. CONCLUSION: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.

Fixed- vs. variable-angle humeral neck cut in anatomic total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Variable neck-shaft angle (NSA) stemmed humeral components have been incorporated into certain implant designs to better re-create normal anatomy in total shoulder arthroplasty (TSA). The purpose of this study was to determine if premorbid glenohumeral joint anatomy is better restored with a fixed- vs. variable-NSA prosthesis. METHODS: A randomized controlled trial was performed including 50 patients with osteoarthritis indicated for primary anatomic TSA. Patients were randomized preoperatively to receive either a variable- (n = 26) or fixed-NSA (n = 24) prosthesis. Humeral neck cut in the variable-NSA group matched the patient's anatomic neck, with prosthetic NSA of 127.5°, 132.5°, and 137.5° available. Fixed-NSA cuts were made with an intramedullary guide of 132.5°. Preoperative and postoperative radiographs were evaluated for specific radiographic anatomic variables: NSA, head thickness, tuberosity-to-head height, head offset, articular arc, greater tuberosity offset, and center of rotation (COR). Postoperative radiographic criteria were compared between groups. RESULTS: No differences were found between groups in demographics or preoperative radiographic measures. When comparing average difference in preoperative and postoperative measurements in the fixed-NSA group, the humeral head offset from the humeral shaft axis significantly decreased by 1.4 mm (P = .046), and the COR moved superiorly (3.0 mm, P = .002) without significant medialization or lateralization. In the variable angle group, humeral head offset decreased but did not reach significance (1.2 mm, P = .091), and the COR also moved superiorly (2.9 mm, P < .001) without significant medialization or lateralization. All remaining radiographic parameters did not significantly change from pre- to postoperative imaging. In comparing the fixed- and variable-NSA groups' net change from the premorbid measurements, no significant differences were found in tuberosity-to-head height, head offset, or COR position in both the horizontal and vertical planes. CONCLUSIONS: Both fixed- and variable-NSA anatomic TSA humeral components demonstrate adequate restoration of premorbid anatomy radiographically.

Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ?

BACKGROUND: Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making. METHODS: We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ2 tests, respectively. RESULTS: Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P < .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001). CONCLUSIONS: ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.

Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?

BACKGROUND: Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. METHODS: An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. RESULTS: A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. CONCLUSION: Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference?

BACKGROUND: Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend toward shorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy. METHODS: We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem design were collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft angle were performed. Restoration of the native humeral anatomy was deemed "acceptable" based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed. RESULTS: In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptable HH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P < .001). CONCLUSION: Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.

Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study.

BACKGROUND: Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR). METHODS: Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery. RESULTS: A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05). CONCLUSION: Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.

Predictors of acromial and scapular stress fracture after reverse shoulder arthroplasty: a study by the ASES Complications of RSA Multicenter Research Group.

BACKGROUND: Acromial (ASF) and scapular spine (SSF) stress fractures are well-recognized complications of reverse shoulder arthroplasty (RSA), but much of the current data are derived from single-center or single-implant studies with limited generalizability. This study from the American Shoulder and Elbow Surgeons (ASES) Complications of Reverse Shoulder Arthroplasty Multicenter Research Group determined the incidence of ASF/SSF after RSA and identified preoperative patient characteristics associated with their occurrence. METHOD: Fifteen institutions including 21 ASES members across the United States participated in this study. Patients undergoing either primary or revision RSA between January 2013 and June 2019 with a minimum 3-month follow-up were included. All definitions and inclusion criteria were determined using the Delphi method, an iterative survey process involving all primary investigators. Consensus was achieved when at least 75% of investigators agreed on each aspect of the study protocol. Only symptomatic ASF/SSF diagnosed by radiograph or computed tomography were considered. Multivariable logistic regression was performed to identify factors associated with ASF/SSF development. RESULTS: We identified 6755 RSAs with an average follow-up of 19.8 months (range, 3-94). The total stress fracture incidence rate was 3.9% (n = 264), of which 3.0% (n = 200) were ASF and 0.9% (n = 64) were SSF. Fractures occurred at an average 8.2 months (0-64) following RSA with 21.2% (n = 56) following a trauma. Patient-related factors independently predictive of ASF were chronic dislocation (odds ratio [OR] 3.67, P = .04), massive rotator cuff tear without arthritis (OR 2.51, P < .01), rotator cuff arthropathy (OR 2.14, P < .01), self-reported osteoporosis (OR 2.21, P < .01), inflammatory arthritis (OR 2.18, P < .01), female sex (OR 1.51, P = .02), and older age (OR 1.02 per 1-year increase, P = .02). Factors independently associated with the development of SSF included osteoporosis (OR 2.63, P < .01), female sex (OR 2.34, P = .01), rotator cuff arthropathy (OR 2.12, P = .03), and inflammatory arthritis (OR 2.05, P = .03). CONCLUSION: About 1 in 26 patients undergoing RSA will develop a symptomatic ASF or SSF, more frequently within the first year of surgery. Our results indicate that severe rotator cuff disease may play an important role in the occurrence of stress fractures following RSA. This information can be used to counsel patients about potential setbacks in recovery, especially among older women with suboptimal bone health. Strategies for prevention of ASF and SSF in these at-risk patients warrant further study. A follow-up study evaluating the impact of prosthetic factors on the incidence rates of ASF and SSF may prove highly valuable in the decision-making process.

Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring?

Cutibacterium acnes is a lipophilic, anaerobic, gram-positive bacillus that mainly colonizes the pilosebaceous glands of human skin. It has been implicated as the leading cause of prosthetic joint infection (PJI) after shoulder arthroplasty. However, PJI caused by C acnes rarely manifests as overt clinical, laboratory, or imaging features. In fact, more than 40% of shoulders undergoing revision arthroplasty are likely to be culture positive. However, rates of infection following a positive culture can be as low as 5%. The purpose of this review was to put forth alternative explanations for this discordance between positive cultures and infection. We describe C acnes roles as a commensal, bystander, and/or contaminant organism; the role of cultures in diagnosis and other methods that may be more accurate; its existence in a shoulder microbiome; and the variable virulence of C acnes. C acnes is an important cause of shoulder PJI in some patients. However, there is a large body of literature that suggests other functions that need to be considered. Further research is needed to define the role of C acnes that is logically explained by all of the literature and not only some.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial.

BACKGROUND: The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up. METHODS: This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses. RESULTS: In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001). CONCLUSION: Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions.

BACKGROUND: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. METHODS: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. RESULTS: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. CONCLUSION: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.

The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty.

BACKGROUND: Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). METHODS: All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room). RESULTS: There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001). CONCLUSIONS: Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.

Distal Mononeuropathy Before and After Arthroscopic Rotator Cuff Repair: A Prospective Investigation.

PURPOSE: The purpose of this study was to characterize the occurrence of distal mononeuropathy (DMN) in patients before and after arthroscopic rotator cuff repair (RCR) as well as resolution of the symptoms. METHODS: One hundred one patients over the age of 18 undergoing arthroscopic RCR +/- concurrent procedures completed a questionnaire regarding the presence of a symptomatic DMN. Patients with history of diabetic neuropathy, cervical radiculopathy, brachial plexopathy, or Spurling sign were excluded. All patients underwent physical examination to determine the characteristics and location of symptoms. Postoperatively, patients underwent repeat examination at 2, 6, and 12 weeks. RESULTS: Preoperatively, 19% (19/101) of RCR patients described DMN symptoms (9 median nerve symptoms, 5 ulnar nerve symptoms, 4 nonspecific symptoms, one with both ulnar and median nerve symptoms). Ninety percent (17/19) patients with preoperative DMN symptoms described resolution within the final 12 weeks of follow-up. A portion of previously asymptomatic RCR patients (12/82) developed new DMN symptoms (6 nonspecific symptoms, 3 ulnar nerve symptoms, 2 median nerve symptoms, one radial sensory nerve symptoms) postoperatively, with 92% (11/12) having resolution by the final 12-week follow-up. At the final 12 weeks, 3 RCR patients had DMN symptoms with 2 of those 3 patients having their symptoms existing preoperatively. CONCLUSIONS: This study supports the hypothesis that DMN can be a preexisting finding in patients undergoing arthroscopic RCR. Similarly, it is common for patients undergoing arthroscopic RCR to develop new DMN symptoms following their procedure. Regardless, there is good evidence to show that a large majority of both groups of patients will go on to have resolution of their symptoms. LEVEL OF EVIDENCE: Level IV, prospective case series.

Treatment of periprosthetic joint infection of the elbow: 15-year experience at a single institution.

BACKGROUND: Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center. METHODS: An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA. RESULTS: A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications. CONCLUSION: Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups.

Outcomes of an anatomic total shoulder arthroplasty with a contralateral reverse total shoulder arthroplasty.

BACKGROUND: It is common for patients to require staged bilateral shoulder arthroplasties. There is a unique cohort of patients who require an anatomic total shoulder arthroplasty (TSA) and a contralateral reverse shoulder arthroplasty (RSA). This study compared the outcomes of patients with a TSA in 1 shoulder and an RSA in the contralateral shoulder. METHODS: Our institutional database was queried to identify all patients with a TSA and a contralateral RSA. Data collection included patient demographics, preoperative and latest follow-up shoulder range of motion, radiographic analysis, and postoperative complications. Identified patients were assessed at follow-up visits or contacted by phone for functional outcome scores. RESULTS: Nineteen patients met our inclusion/exclusion criteria. There was statistically significant greater internal rotation in the TSA shoulder (P= .044) but no significant difference in forward elevation (P = .573) or external rotation (P= .368). There was no radiographic evidence of humeral or glenoid component loosening of any arthroplasty implants. There were no significant differences between TSA and RSA shoulders for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (P= .381), Simple Shoulder Test (P = .352), Single Assessment Numerical Evaluation (P = .709), and visual analog scale satisfaction (P= .448) or pain scores (P= .305). Thirteen patients (68.4%) preferred the RSA side, 1 patient (5.3%; z = 4.04, P < .001) patient preferred the TSA side, and 5 patients expressed no preference. CONCLUSION: Despite known limitations and differences between TSA and RSA designs, patients who have received both implants are highly satisfied with both. The only parameter in which the TSA had superior outcomes was internal rotation.

Functional outcomes of distal triceps tendon repair comparing transosseous bone tunnels with suture anchor constructs.

BACKGROUND: Distal triceps tendon ruptures are relatively rare. Few studies have investigated functional outcomes after repair. There is no consensus on fixation methods for this injury. The purpose of this study was to compare the functional outcomes and the reoperation rates after distal triceps tendon repairs using transosseous tunnels and suture anchors. METHODS: A multicenter, retrospective review of all primary triceps repairs done between 2006 and 2015 was performed. Patients were included if they had a minimum of 2 years of follow-up. Intraoperative data recorded included repair method and number of anchors used when applicable. Patients were contacted for functional assessment with the Mayo Elbow Performance Score (MEPS). Postoperative complications were also queried. RESULTS: There were 56 cases of primary triceps repair identified in an all-male cohort. Average age at time of surgery was 52.7 years; 58.9% of patients had transosseous repair, and 41.1% had suture anchor repair. The average follow-up was 4.26 years. The average postoperative MEPS score for all patients was 94. There was no difference in MEPS outcomes based on construct type. Postoperative Disabilities of the Arm, Shoulder, and Hand scores had an overall average of 4.81. A statistically significant difference was found, with the transosseous group averaging 2.98 points lower than the suture anchor group. This difference was not found to be clinically relevant. Only 4 patients had rerupture of the triceps requiring revision. CONCLUSIONS: Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct.

Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.

BACKGROUND: Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections. Most reports have found a high rate of P acnes infection after open surgery, particularly shoulder arthroplasty. However, there are limited data regarding P acnes infections after shoulder arthroscopy. MATERIALS AND METHODS: We prospectively collected data on all shoulder arthroscopies performed by the senior author from January 1, 2009, until April 1, 2013. Cultures were taken in all revision shoulder arthroscopy cases performed for pain, stiffness, or weakness. In addition, 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate. RESULTS: A total of 1,591 shoulder arthroscopies were performed during this period, 68 (4.3%) of which were revision procedures performed for pain, stiffness, or weakness. A total of 20 revision arthroscopies (29.4%) had positive culture findings, and 16 (23.5%) were positive for P acnes. In the control group, 1 patient (3.2%) had P acnes growth. CONCLUSIONS: The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness.