Comparison of 3D Computer Assisted Planning With and Without Patient Specific Instrumentation for Severe Bone Defects in Reverse Total Shoulder Arthroplasty.

BACKGROUND: Preoperative planning is an integral aspect of managing complex deformity in reverse shoulder arthroplasty (RSA). The purpose of this study was to compare the success of patient specific instrumentation (PSI) and 3D computer-assisted planning with standard instrumentation (Non-PSI) in achieving planned corrections of the glenoid among patients undergoing RSA with severe bony deformity requiring glenoid bone grafts. METHODS: A retrospective case-control study was performed, including all patients that underwent RSA with combined bone grafting procedures (BIO-RSA or structural bone grafting) for severe glenoid deformity by a single between June 2016 and July 2023. Patients were required to have preoperative and postoperative CT scans as well as preoperative 3D planning performed for inclusion. Patients were divided into two groups based on the use of 3D computer-assisted planning with or without PSI (PSI vs. Non-PSI). The corrected inclination and version were measured by two separate reviewers on preoperative and postoperative 2D CT scans and compared to their corresponding preoperative planning goals utilizing bivariate analyses. RESULTS: We identified 45 patients that met our inclusion criteria (22 PSI and 23 Non-PSI). Preoperative inclination (mean ± SD) (PSI 10.12° ± 15.86°, Non-PSI 9.43° ± 10.64°; P = 0.864) and version (PSI -18.78° ± 18.3°, Non-PSI -17.82° ± 11.49°; P = 0.835) measurements were similar between groups. No significant differences in the mean deviation (error) between the postoperative and planned inclination (PSI 5.49° ± 3.72; Non-PSI 6.91° ± 5.05; P = 0.437) and version (PSI 8.37° ± 5.7; Non-PSI 5.37° ± 4.43; P = 0.054) were found between groups. No difference in the rate of outliers (>10° error) was noted in inclination (P = 0.135) or version (P = 0.445) between groups. Greater planned version correction was correlated with greater error when PSI was utilized (PSI r = 0.519, P = 0.013; Non-PSI r = 0.362, P = 0.089). CONCLUSION: Both PSI and 3D computer-assisted planning without PSI (Non-PSI) appear to be useful techniques to achieve version and inclination correction among patients undergoing RSA with severe glenoid deformity required glenoid bone grafting with no clear superiority of one method over the other. Surgeons should be aware that when utilizing PSI, slightly greater error in achieving version goals may occur as version correction is increased.

Clinically significant outcome thresholds and rates of achievement by shoulder arthroplasty type and preoperative diagnosis.

BACKGROUND: Clinically significant outcome (CSO) benchmarks have been previously established for shoulder arthroplasty by assimilating preoperative diagnoses and arthroplasty types. The purpose of this study was to establish unique CSO thresholds and compare the time-to-achievement of these for reverse shoulder arthroplasty (RSA) for osteoarthritis (GHOA), RSA for rotator cuff arthropathy (RCA), and total shoulder arthroplasty (TSA) for GHOA. MATERIALS AND METHODS: Consecutive patients who underwent elective RSA for GHOA, TSA for GHOA, or RSA for RCA between February 2015 and May 2020, with 2-year minimum follow-up, were retrospectively identified from a prospectively maintained single surgeon registry. The American Shoulder and Elbow Surgeons (ASES) score was administered preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year timepoints. Satisfaction and subjective overall improvement anchor questionnaires were administered at the time of final follow-up. Distribution-based methods were used to calculate the Minimal Clinically Important Difference (MCID), and anchor-based methods were used to calculate the Substantial Clinical Benefit (SCB) and the Patient Acceptable Symptom State (PASS) for each patient group. Median time to achievement, individual incidence of achievement at each time point, and cumulative incidence of achievement calculated using Kaplan-Meier survival curve analysis with interval censoring were compared between groups for each CSO. Cox-regression analyses were also performed to determine which patient factors were significantly associated with early or delayed achievement of CSOs. RESULTS: There were 471 patients eligible for study analysis: 276 RSA for GHOA, 107 TSA for GHOA, and 88 RSA for RCA. The calculated MCID, SCB, and PASS scores differed for each group. There were no significant differences in median time to achievement of any CSO between groups. Log-rank testing revealed that cumulative achievements significantly differed between groups for MCID (P = .014) but not for SCB (P = .053) or PASS (P = .620). On cox regression analysis, TSA patients had earlier achievement of SCB, whereas TSA and RSA for GHOA patients had earlier achievement of MCID. At 2-years, a significantly higher percentage of RSA for GHOA patients achieved MCID and SCB compared to RSA for RCA (MCID:100%, 95.5%, P = .003, SCB:94.6%, 86.4%, P = .036). CONCLUSION: Calculated CSO thresholds differ according to preoperative diagnosis and shoulder arthroplasty type. Patients undergoing TSA and RSA for GHOA achieve CSOs earlier than RSA for RCA patients, and a significantly higher percentage of RSA for GHOA patients achieve CSOs by 2 years compared to RSA for RCA patients.

The Majority of Sports Medicine and Arthroscopy-Related Randomized Controlled Trials Reporting Nonsignificant Results Are Statistically Fragile.

PURPOSE: To evaluate the robustness of sports medicine and arthroscopy related randomized controlled trials (RCTs) reporting nonsignificant results by calculating the reverse fragility index (RFI) and reverse fragility quotient (RFQ). METHODS: All sports medicine and arthroscopic-related RCTs from January 1, 2010, through August 3, 2021, were identified. Randomized-controlled trials comparing dichotomous variables with a reported P value ≥ .05 were included. Study characteristics, such as publication year and sample size, as well as loss to follow-up and number of outcome events were recorded. The RFI at a threshold of P < .05 and respective RFQ were calculated for each study. Coefficients of determination were calculated to determine the relationships between RFI and the number of outcome events, sample size, and number of patients lost to follow-up. The number of RCTs in which the loss to follow-up was greater than the RFI was determined. RESULTS: Fifty-four studies and 4,638 patients were included in this analysis. The mean sample size and loss to follow-up were 85.9 patients and 12.5 patients, respectively. The mean RFI was 3.7, signifying that a change of 3.7 events in one arm was needed to flip the results of the study from non-significant to significant (P < .05). Of the 54 studies investigated, 33 (61%) had a loss to follow-up greater than their calculated RFI. The mean RFQ was 0.05. A significant correlation between RFI with sample size (R2 = 0.10, P = .02) and the total number of observed events (R2 = 0.13, P < .01) was found. No significant correlation existed between RFI and loss to follow-up in the lesser arm (R2 = 0.01, P = .41). CONCLUSIONS: The RFI and RFQ are statistical tools that allow the fragility of studies reporting nonsignificant results to be appraised. Using this methodology, we found that the majority of sports medicine and arthroscopy-related RCTs reporting nonsignificant results are fragile. CLINICAL RELEVANCE: RFI and RFQ serve as tools that can be used to assess the validity of RCT results and provide additional context for appropriate conclusions.

Patients With Functional Somatic Syndromes-Fibromyalgia, Irritable Bowel Syndrome, Chronic Headaches, and Chronic Low Back Pain-Have Lower Outcomes and Higher Opioid Usage and Cost After Shoulder and Elbow Surgery.

PURPOSE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery. METHODS: A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs. RESULTS: The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs. CONCLUSIONS: Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline. LEVEL OF EVIDENCE: Level III, systematic review of Level II-III studies.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

PURPOSE: The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. METHODS: A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. RESULTS: Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. CONCLUSION: The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. LEVEL OF EVIDENCE: Level I.

Preoperative allergy testing for patients reporting penicillin and cephalosporin allergies is economically justified in preventing infection after total shoulder arthroplasty.

BACKGROUND: The use of alternative antibiotics to cefazolin has been associated with increased risk of infection after shoulder arthroplasty. Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin and may reduce the occurrence of infection after shoulder arthroplasty, but the financial viability of this practice is unclear. We used break-even modeling to determine the economic viability of routine preoperative allergy testing for infection prevention in total shoulder arthroplasty patients reporting penicillin and cephalosporin allergies. METHODS: Allergy testing cost ($248.24), infection rates after shoulder arthroplasty following use of noncefazolin antibiotics (3.09%), and infection-related care costs ($55,243) were derived from the literature. A break-even equation using these variables was developed to determine the absolute risk reduction (ARR) in the infection rate that would economically justify the routine implementation of preoperative allergy testing. The number needed to treat was calculated from the ARR. RESULTS: Preoperative allergy testing is considered economically justified if it prevents at least 1 infection out of 223 shoulder arthroplasties (ARR = 0.45%). These protocols remained economically viable at varying allergy testing costs, initial infection rates, and infection-related care costs. CONCLUSIONS: Routine preoperative penicillin allergy testing is an economically justified infection prevention strategy among patients reporting penicillin and cephalosporin allergies in the setting of elective shoulder arthroplasty. Widespread implementation of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.

Intraosseous Regional Administration of Antibiotic Prophylaxis for Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA). METHODS: PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics. RESULTS: All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 µg/g [fat] and 49.3 µg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 µg/g [fat] and 5.2 µg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively. CONCLUSION: Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit.

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review.

BACKGROUND: As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed. QUESTIONS/PURPOSES: We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated? METHODS: The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]). RESULTS: The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]). CONCLUSION: There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty. CLINICAL RELEVANCE: Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.

Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review.

BACKGROUND: The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF). METHODS: The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded. RESULTS: Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%). CONCLUSION: Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.

Functional somatic syndromes are associated with suboptimal outcomes and high cost after shoulder arthroplasty.

BACKGROUND: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs. METHODS: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores. RESULTS: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001). CONCLUSIONS: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.

The association between anterior shoulder joint capsule thickening and glenoid deformity in primary glenohumeral osteoarthritis.

BACKGROUND: Anterior shoulder joint capsule thickening is typically present in osteoarthritic shoulders, but its association with specific patterns of glenoid wear is incompletely understood. We sought to determine the relationship between anterior capsular thickening and glenoid deformity in primary glenohumeral osteoarthritis. METHODS: We retrospectively identified 134 consecutive osteoarthritic shoulders with magnetic resonance imaging and computed tomography scans performed. Axial fat-suppressed magnetic resonance imaging slices were used to quantify the anterior capsular thickness in millimeters, measured at its thickest point below the subscapularis muscle. Computed tomography scans were used to classify glenoid deformity according to the Walch classification, and an automated 3-dimensional software program provided values for glenoid retroversion and humeral head subluxation. Multinomial and linear regression models were used to characterize the association of anterior capsular thickening with Walch glenoid type, glenoid retroversion, and posterior humeral head subluxation while controlling for patient age and sex. RESULTS: The anterior capsule was thickest in glenoid types B2 (5.5 mm, 95% confidence interval [CI]: 5.0-6.0) and B3 (6.1 mm, 95% CI: 5.6-6.6) and thinnest in A1 (3.7 mm, 95% CI: 3.3-4.2; P < .001). Adjusted for age and sex, glenoid types B2 (odds ratio: 4.4, 95% CI: 2.3-8.4, P < .001) and B3 (odds ratio: 5.4, 95% CI: 2.8-10.4, P < .001) showed the strongest association with increased anterior capsule thickness, compared to glenoid type A1. Increased capsular thickness correlated with greater glenoid retroversion (r = 0.57; P < .001) and posterior humeral head subluxation (r = 0.50; P < .001). In multivariable analysis, for every 1-mm increase in anterior capsular thickening, there was an adjusted mean increase of 3.2° (95% CI: 2.4-4.1) in glenoid retroversion and a 3.8% (95% CI: 2.7-5.0) increase in posterior humeral head subluxation. CONCLUSIONS: Increased thickening of the anterior shoulder capsule is associated with greater posterior glenoid wear and humeral head subluxation. Additional research should determine whether anterior capsular disease plays a causative role in the etiology or progression of eccentric glenohumeral osteoarthritis.

Neighborhood socioeconomic disadvantage does not predict outcomes or cost after elective shoulder arthroplasty.

BACKGROUND: There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty. METHODS: We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores. RESULTS: Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77). CONCLUSIONS: Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.

Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty.

BACKGROUND: Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption. METHODS: We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables. RESULTS: Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (ß, 0.14; 95% confidence interval, 0.02-0.42; P = .035). CONCLUSION: LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

Rotator cuff fatty infiltration and muscle atrophy: relation to glenoid deformity in primary glenohumeral osteoarthritis.

BACKGROUND: Muscle atrophy (MA) and fatty infiltration (FI) are degenerative processes of the rotator cuff musculature that have incompletely understood relationships with the development of eccentric glenoid wear in the setting of primary glenohumeral osteoarthritis (GHOA). METHODS: All patients with GHOA and an intact rotator cuff who underwent both magnetic resonance imaging and computed tomography scans of the affected shoulder prior to total shoulder arthroplasty between 2015 and 2020 were identified from a prospectively maintained registry. Rotator cuff MA was measured quantitatively on sequential sagittal magnetic resonance images, whereas FI was assessed on sagittal magnetic resonance imaging slices using the Goutallier classification. Preoperative computed tomography scans were reconstructed using automated 3-dimensional software to determine glenoid retroversion, glenoid inclination, and humeral head subluxation. Glenoid deformity was classified according to the Walch classification. Univariate and multivariable regression analyses were performed to characterize associations between age, sex, muscle area, FI, and glenoid morphology. RESULTS: Among the 127 included patients, significant associations were found between male sex and larger overall rotator cuff musculature (P < .01), increased ratio of the posterior rotator cuff (PRC) to the subscapularis area (P = .01), and glenoid retroversion (19° vs. 14°, P < .01). Larger supraspinatus and PRC muscle size was correlated with increased retroversion (r = 0.23 [P = .006] for supraspinatus and r = 0.25 [P = .004] for PRC) and humeral head subluxation (r = 0.25 [P = .004] for supraspinatus and r = 0.28 [P = .001] for PRC). The ratio of PRC muscle size to anterior rotator cuff muscle size was not associated with evidence of eccentric glenoid wear (P > .05). After we controlled for confounding factors, increasing glenoid retroversion was associated with high-grade infraspinatus FI (ß, 6.8; 95% confidence interval, 2.9-10.7; P < .01) whereas larger PRC musculature was predictive of a Walch type B (vs. type A) glenoid (odds ratio, 1.3; 95% confidence interval, 1.0-1.5; P = .04). CONCLUSION: Patients with eccentric glenoid wear in the setting of primary GHOA and an intact rotator cuff appear to have both larger PRC musculature and higher rates of infraspinatus FI. Although the temporal and causal relationships of these associations remain ambiguous, MA and FI should be considered 2 discrete processes in the natural history of GHOA.

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients.

BACKGROUND: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients. METHODS: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT). RESULTS: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates. CONCLUSION: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.

Adverse Events Associated With Robotic-Assisted Joint Arthroplasty: An Analysis of the US Food and Drug Administration MAUDE Database.

BACKGROUND: The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes. METHODS: Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact. RESULTS: Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn. CONCLUSION: Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects.

Public Opinion and Expectations of Stem Cell Therapies in Orthopaedics.

PURPOSE: To explore public opinion, understanding, and preferences regarding the use of stem cell therapies for the treatment of joint and tendon pathologies using online crowdsourcing. METHODS: A 30-question survey was completed by 931 members of the public using Amazon Mechanical Turk, a validated crowdsourcing method. Outcomes included perceptions and preferences regarding the use of stem cells therapies for the nonsurgical treatment of orthopaedic conditions. Sociodemographic factors and a validated assessment of health literacy were collected. Inclusion criteria were adult participants 18 years or older, residence within the United States, and a valid Social Security number. Multivariable logistic regression modeling was used to determine population characteristics associated with the belief that stem cells represent the most effective treatment for long-standing joint or tendon disorders. RESULTS: Most respondents reported that stem cell therapies have convincing evidence to support their use for orthopaedic conditions (84.5%) and are approved and regulated by the Food and Drug Administration (65%). About three-quarters of respondents reported that stem cells can stop the progression of and alleviate pain from arthritis or damaged tendons, and over half (53.5%) reported that stem cells can cure arthritis. Factors with the greatest influence on respondents' decision to receive stem cell therapies are research supporting their safety and effectiveness and doctor recommendation. However, 63.3% of respondents stated that they would consider stem cells if their doctor recommended it, regardless of evidence supporting their effectiveness, and over half would seek another doctor if their orthopaedic surgeon did not offer this treatment option. CONCLUSIONS: The public's limited understanding regarding the current evidence associated with stem cell therapies for osteoarthritis and tendinous pathologies may contribute to unrealistic expectations and misinformed decisions. This study highlights the importance of patient education and expectation setting, as well as evidence transparency, as stem cell therapies become increasingly accessible. LEVEL OF EVIDENCE: Level IV, case series.

Vancomycin Presoaking of Anterior Cruciate Ligament Tendon Grafts Is Highly Cost-Effective for Preventing Infection.

PURPOSE: This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs. METHODS: Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR. RESULTS: Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin. CONCLUSIONS: Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction. LEVEL OF EVIDENCE: IV, economic analysis.

Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study.

BACKGROUND: Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence. METHODS: Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs. RESULTS: Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P < .05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P < .05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P < .05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P < .05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05). CONCLUSIONS: The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery.

Rotator cuff fatty infiltration and muscle atrophy do not impact clinical outcomes after reverse total shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff.

BACKGROUND: The clinical significance of rotator cuff muscle quality following reverse total shoulder arthroplasty (RTSA) remains uncertain. The purpose of this study was to evaluate the influence of rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on clinical outcomes following RTSA for glenohumeral osteoarthritis (GHOA). METHODS: One hundred eight shoulders with primary GHOA that underwent RTSA with a lateralized glenosphere for GHOA with a minimum of 2-year follow-up were identified from a prospectively maintained registry. Each rotator cuff muscle was assessed on preoperative magnetic resonance imaging for FI and quantitative amount of MA. Pre- and postoperative outcomes included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numerical Evaluation (SANE) score, visual analog scale pain score, and range of motion (ROM) measurements. RESULTS: Eighty-one patients with a mean age of 70.7 ± 5.4 years (range: 57-85) were included who underwent RTSA with a mean follow-up of 2.1 years (range: 2-3.9 years). There was a significant improvement in all outcome measures postoperatively (P < .01). Twenty-two patients (27.1%) had moderate to severe combined infraspinatus and teres minor FI. There was no significant difference in the postoperative external rotation or clinical outcomes compared with those patients with only mild FI (P > .05). Forty-three patients (53.1%) had moderate to severe global rotator cuff FI. There was no significant difference in postoperative outcomes compared with those patients with only mild FI (P < .01). Univariate analysis did not reveal any significant association between the degree of FI or MA of any individual rotator cuff muscle and postoperative clinical outcomes or ROM. The size ratio of the posterior rotator cuff to the subscapularis muscle was positively correlated with preoperative SANE scores but negatively correlated with absolute postoperative and change in preoperative to postoperative SANE scores. However, there were no significant correlations between this size ratio and the other outcome measures. CONCLUSION: Rotator cuff muscle quality as assessed by MA and FI does not impact clinical outcomes following RTSA with a lateralized glenosphere in patients with GHOA and an intact rotator cuff.