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BACKGROUND: Social determinants of health (SDOH) are the collection of environmental, institutional, and intrinsic conditions that may bias access to, and utilization of, health care across an individual's lifetime. The effects of SDOH are associated with disparities in patient-reported outcomes after hip and knee arthroplasty, but its impact on rotator cuff repair (RCR) is poorly understood. This study aimed to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following RCR. METHODS: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and guidelines outlined by the Cochrane Collaboration. A search of PubMed, the Cochrane Library, and Embase from inception until March 2022 was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following RCR. The search term was created with reference to the PROGRESS-Plus framework. Methodological quality of included primary studies was appraised using the Newcastle-Ottawa Scale (NOS) for nonrandomized studies, and the Cochrane Risk of Bias Tool for randomized studies. RESULTS: Thirty-two studies (level I-IV evidence) from 18 journals across 7 countries, published between 1999 and 2022, met inclusion criteria, including 102,372 patients, 669 physical therapy (PT) clinics, and 71 orthopedic surgery practices. Multivariate analysis revealed female gender, labor-intensive occupation and worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial or ethnic minority status, low-income place of residence and low-volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to health care and/or more severe disease state on presentation. Black race patients were found to have significantly worse postoperative clinical and patient-reported outcomes and experienced more pain following RCR. Furthermore, Black and Hispanic patients were more likely to present to low-volume surgeons and low-volume facilities. A lower education level was shown to be an independent predictor of poor surgical and patient-reported outcomes as well as increased pain and worse patient satisfaction. Patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes CONCLUSIONS: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.
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Artroplastia do Joelho , Lesões do Manguito Rotador , Humanos , Feminino , Manguito Rotador/cirurgia , Lesões do Manguito Rotador/cirurgia , Lesões do Manguito Rotador/complicações , Etnicidade , Determinantes Sociais da Saúde , Grupos Minoritários , Dor , Resultado do Tratamento , ArtroscopiaRESUMO
BACKGROUND: Compared with the overall incidence of shoulder arthroplasty (SA), the relative risk and burden of revision may vary among patients specifically 40-50 years of age and less than 40 years of age. Our aim was to investigate the incidence of primary anatomic total SA and reverse SA, rate of revision within 1 year, and determine the associated economic burden in patients younger than 50 years. METHODS: A total of 509 patients less than 50 years old who underwent SA were included, using a national private insurance database. Costs were based on the grossed covered payment. Multivariate analyses were performed to identify risk factors associated with revisions within 1 year of the index procedure. RESULTS: SA incidence in patients less than 50 years old increased from 2.21 to 2.5 per 100,000 patients from 2017 to 2018. The overall revision rate was 3.9% with a mean time to revision of 96.3 days. Diabetes was a significant risk factor for revision (P = .043). Surgeries performed in patients less than 40 years old cost more than those performed in patients aged 40-50 years for both primary ($41,943 ± $23,842 vs. $39,477 ± $20,874) and revision cases ($40,370 ± $21,385 vs. $31,669 ± $10,430). CONCLUSIONS: This study demonstrates that the incidence of SA in patients less than 50 years old is higher than previously reported in the literature and most commonly reported for primary osteoarthritis. Given the high incidence of SA and subsequent high early revision rate in this subset population, our data portend a large associated socioeconomic burden. Policymakers and surgeons should use these data for implementing training programs focused on joint sparing techniques.
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Artroplastia do Ombro , Articulação do Ombro , Humanos , Pessoa de Meia-Idade , Adulto , Artroplastia do Ombro/efeitos adversos , Articulação do Ombro/cirurgia , Incidência , Resultado do Tratamento , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies. METHODS: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies. RESULTS: A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11). CONCLUSIONS: Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.
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Lesões do Manguito Rotador , Manguito Rotador , Animais , Bovinos , Humanos , Artroplastia/métodos , Artroscopia/métodos , Manguito Rotador/cirurgia , Lesões do Manguito Rotador/cirurgia , Resultado do Tratamento , Ensaios Clínicos Controlados como AssuntoRESUMO
BACKGROUND: Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA. METHODS: A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables. RESULTS: Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P < .001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P > .05). CONCLUSION: Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way.
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Artroplastia do Ombro , Osteoartrite , Articulação do Ombro , Humanos , Osteoartrite/diagnóstico por imagem , Osteoartrite/patologia , Osteoartrite/cirurgia , Dor/cirurgia , Amplitude de Movimento Articular , Estudos Retrospectivos , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/patologia , Articulação do Ombro/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Currently, appropriateness criteria evaluating when to perform total shoulder arthroplasty (TSA) is lacking. In the absence of society guidelines and limited quality evidence, the RAND/University California in Los Angeles (UCLA) method provides a suitable alternative to evaluate appropriateness and assist in clinical decision making. Given the rise in utilization, appropriateness criteria for TSA have the potential to be an extremely powerful tool for improving quality of care and controlling costs. Thus, the goal of this study was to test explicit criteria to assess the appropriateness of TSA decision making using the RAND/UCLA appropriateness method. METHODS: A review of recent scientific literature to gather available evidence about the use, effectiveness, efficiency, and the risks involved in surgical intervention was performed by a shoulder/elbow fellowship trained physician. Based on pertinent variables including age, rotator cuff status, previous surgical management, mobility, symptomatology, and imaging classifications, 186 clinical scenarios were created. Appropriateness criteria for TSA were developed using a modified Delphi method with a panel consisting of American Shoulder and Elbow Surgeons (ASES) members. A second panel of ASES members rated the same scenarios, with reliability testing performed to compare groups. RESULTS: Panel members reached agreement in 40 (64%) indications. TSA was appropriate in 15 (24%) of indications. For patients with severe symptomatology, TSA was often appropriate for patients aged <75 years and inconclusive or inappropriate for patients aged >75 years. Among patients aged <65 years, TSA varied between appropriate and inconclusive, often dependent on Walch classification. For patients with moderate symptomatology, TSA was inappropriate or inconclusive for patients aged <65 or >75 years. When compared to the second panel's results, moderate agreement was obtained with a weighted kappa statistic of 0.56. CONCLUSIONS: Using the RAND/UCLA method, ASES members created an appropriateness decision tree for pertinent patient variables. This presents the data in a manner that streamlines the clinical decision-making process and allows for rapid and more reliable determination of appropriateness for practitioners. The decision tree is based on a combination of clinical experience from high-volume ASES-member surgeons and a comprehensive review of current evidence. This tool can be used as part of a broader set of factors, including individual patient characteristics, prior studies, and expert opinion, to inform clinical decision making, improve quality of care, and control costs.
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Artroplastia do Ombro , Algoritmos , Humanos , Los Angeles , Reprodutibilidade dos Testes , Resultado do Tratamento , UniversidadesRESUMO
PURPOSE: To create and determine face validity and content validity of arthroscopic rotator cuff repair (ARCR) performance metrics, to confirm construct validity of the metrics coupled with a cadaveric shoulder, and to establish a performance benchmark for the procedure on a cadaveric shoulder. METHODS: Five experienced arthroscopic shoulder surgeons created step, error, and sentinel error metrics for an ARCR. Fourteen shoulder arthroscopy faculty members from the Arthroscopy Association of North America formed the modified Delphi panel to assess face and content validity. Eight Arthroscopy Association of North America shoulder arthroscopy faculty members (experienced group) were compared with 9 postgraduate year 4 or 5 orthopaedic residents (novice group) in their ability to perform an ARCR. Instructions were given to perform a diagnostic arthroscopy and a 2-anchor, 4-simple suture repair of a 2-cm supraspinatus tear. The procedure was videotaped in its entirety and independently scored in blinded fashion by trained, paired reviewers. RESULTS: Delphi panel consensus for 42 steps and 66 potential errors was obtained. Overall performance assessment showed a mean inter-rater reliability of 0.93. Novice surgeons completed 17% fewer steps (32.1 vs 37.5, P = .001) and enacted 2.5 times more errors than the experienced group (6.21 vs 2.5, P = .012). Fifty percent of the experienced group members and none of the novice group members achieved the proficiency benchmark of a minimum of 37 steps completed with 3 or fewer errors. CONCLUSIONS: Face validity and content validity for the ARCR metrics, along with construct validity for the metrics and cadaveric shoulder, were verified. A proficiency benchmark was established based on the mean performance of an experienced group of arthroscopic shoulder surgeons. CLINICAL RELEVANCE: Validated procedural metrics combined with the use of a cadaveric shoulder can be used to accurately assess the performance of an ARCR.
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Artroscopia/métodos , Lesões do Manguito Rotador/cirurgia , Manguito Rotador/cirurgia , Articulação do Ombro/cirurgia , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Gravação em VídeoRESUMO
Studies of saccadic eye movements in subjects with Tourette syndrome (TS) have provided additional evidence that there is a link between TS symptoms and deficits in fronto-striato-thalamic networks. These studies revealed impaired timing and inhibition of saccades. We compared fixational eye movements, such as microsaccades and ocular drifts, in subjects with TS and healthy controls.We measured horizontal and vertical eye positions with video-oculography in 14 subjects with Tourette syndrome. We found reduced microsaccade amplitude but increased time between adjacent microsaccades (intersaccadic interval). Hence, the rate of microsaccades was reduced in subjects with TS compared to controls. Measure of ocular stability during intersaccadic intervals revealed increased drift velocity and increased variance in eye position. We hypothesize that increased activity of the direct fronto-striatal pathway and the resulting reduction in basal ganglia outflow targeting the superior colliculus fixation zone affect the rate and amplitude of microsaccades in subjects with TS. The resulting impairment in frontal eye field fixation leads to increased drifts during intersaccadic interval in subjects with TS. Possible clinical implication for these results is that fixational eye movements can be objective biological markers of TS.
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Fixação Ocular , Síndrome de Tourette/fisiopatologia , Adulto , Idoso , Transtornos de Ansiedade/complicações , Transtornos de Ansiedade/tratamento farmacológico , Transtornos de Ansiedade/fisiopatologia , Transtorno do Deficit de Atenção com Hiperatividade/complicações , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/fisiopatologia , Comorbidade , Medições dos Movimentos Oculares , Feminino , Fixação Ocular/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtorno Obsessivo-Compulsivo/complicações , Transtorno Obsessivo-Compulsivo/tratamento farmacológico , Transtorno Obsessivo-Compulsivo/fisiopatologia , Movimentos Sacádicos/fisiologia , Índice de Gravidade de Doença , Fatores de Tempo , Síndrome de Tourette/complicações , Síndrome de Tourette/tratamento farmacológico , Gravação em Vídeo , Adulto JovemRESUMO
BACKGROUND: Medial epicondylitis of the elbow, an overuse injury characterized by angiofibroblastic tendinosis of the common flexor-pronator origin, generally responds to nonoperative treatment. Refractory cases may require surgical débridement and repair. This study discusses physical examination and imaging findings and an updated surgical technique used in patients with recalcitrant medial epicondylitis. METHODS: The surgical records of 60 patients with refractory medial epicondylitis were reviewed. All received a course of nonoperative care. After 3 to 6 months of failed therapy, imaging was obtained, and surgical intervention was offered when indicated. This open procedure consisted of thorough débridement with repair and restoration of the flexor-pronator origin, using a suture anchor. Accelerated rehabilitation, emphasizing early motion, was used. One-year follow-ups were obtained. The Mayo Elbow Performance Score was calculated preoperatively and postoperatively. RESULTS: Pronation weakness at 90° was a critical physical examination finding. Preoperative magnetic resonance images demonstrated pathologic partial tearing at the flexor-pronator origin. Ulnar neuritis was addressed in 20%. Postoperatively, the Mayo Elbow Performance Score significantly increased (preoperatively, 58 ± 7.7; postoperatively, 88 ± 7.8; P = 5.6E-34), and pain significantly decreased (preoperatively, 2.2 ± 0.3; postoperatively, 0.6 ± 0.5; P = 3.8E-33). There was one retear in a patient noncompliant with the postoperative protocol. He responded positively to reoperation. CONCLUSION: Identification of weakness on pronation is a reliable physical examination finding for determining clinically significant pathologic changes in patients with medial epicondylitis. Débridement with restoration of the flexor-pronator origin is an efficacious procedure. In this large series of patients, surgical repair with aggressive rehabilitation was shown to be reliable and safe in restoring function and relieving pain in recalcitrant cases of medial epicondylitis.
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Articulação do Cotovelo/cirurgia , Exame Físico/métodos , Cotovelo de Tenista/diagnóstico , Cotovelo de Tenista/cirurgia , Desbridamento , Articulação do Cotovelo/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Cuidados Pós-Operatórios , PronaçãoRESUMO
Immobilization for acromial and scapular spine stress AU4fractures (AF/SSF) after reverse total shoulder arthroplasty (RSA) is associated with patient dissatisfaction. Our study reports the effects and safety of intranasal calcitonin alongside sling immobilization on pain and function in the treatment of AF/SSF after RSA. The treatment was regimented calcitonin (salmon) 200 unit/actuation nasal spray (1 spray/day) for 6 weeks with sling immobilization for 4 weeks. Each patient was monitored through blood work. Visual analog scale, American Shoulder and Elbow Surgeons score, and active range of motion were collected preoperatively, postoperatively, at presentation of AF/SSF, and after completion of calcitonin treatment. Two hundred eighty-two RSAs were performed by two board-certified orthopaedic surgeons, of which 18 patients sustained AF/SSF (6.4%). Ten patients met inclusion criteria (nine AFs and one SSF). After calcitonin treatment, patients demonstrated an average improvement of visual analog scale of 5.8 points, active range of motion of 46_, and American Shoulder and Elbow Surgeons score of 43.6 points at average 7.53 months after RSA. No medical complications were reported at 6-month follow-up after calcitonin treatment. The use of intranasal calcitonin was not associated withadverse events including no aberrations/signs of cancer at 6-month follow-up after administration. Calcitonin with sling immobilization markedly improved clinical and functional outcomes of patients with nondisplaced AF/SSF and may be considered by orthopaedic surgeons for symptom management.
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Artroplastia do Ombro , Conservadores da Densidade Óssea , Fraturas de Estresse , Humanos , Calcitonina , Artroplastia do Ombro/efeitos adversos , Uso Off-Label , Escápula , Hormônios e Agentes Reguladores de CálcioRESUMO
Subscapularis insufficiency continues to be a source of morbidity after anatomic total shoulder arthroplasty (TSA). Biologic augmentation following rotator cuff repair has shown promising results. Here we show the technique for performing subscapularis repair after anatomic TSA using a "peel-tenotomy" and bone marrow aspirate concentrate (BMAC). A standard deltopectoral approach is performed. The peel-tenotomy is performed by leaving 0 to 10 mm of subscapularis attached to the lesser tuberosity and peeling off the remainder of the tendon. A trocar is used to aspirate bone marrow from the humeral head, which is then processed. Prior to placing the humeral stem, drill holes are placed at the bicipital groove and lesser tuberosity. Sutures are placed through each drill hole. After impacting the humeral stem, suture is passed through the subscapularis to perform a secure double row repair. Prior to tying the sutures, BMAC is applied along the margins of the subscapularis repair. After securing the sutures, additional BMAC can be applied to the subscapularis repair. It is hypothesized that this technique could provide a more robust subscapularis repair and decrease the rate of subscapularis insufficiency after TSA without any known risk or morbidity to the patient, although further research is needed to show this.
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Background: Biologic healing after rotator cuff repair remains a significant challenge. Injectable biologic augmentation may improve tissue quality at the suture-tendon interface. Purpose: To investigate the effect of injectable biologic supplementation in rotator cuff repair and to assess the quality and adherence to evolving reporting standards. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were 40 studies: 29 preclinical (in vivo animal models) and 11 clinical. Each clinical study was assessed for quality, risk of bias, and adherence to relevant MIBO (Minimum Information for Studies Evaluating Biologics in Orthopaedics) guidelines. The outcomes of interest were reported load to failure, load to gap, gap size, and stiffness in the preclinical studies, and healing rate and any patient-reported outcome measures in the clinical studies. Results: Injectables reported included growth factors (eg, transforming growth factor-beta 3, erythropoietin), bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells (ADSCs), and other agents such as platelet-rich plasma (PRP) and hyaluronic acid. The most common findings for preclinical injectables were increased load to failure (16/29 studies; 55.2%) and improved collagen histological quality (11/29 studies; 37.9%). All 11 clinical studies (10 PRP, 1 ADSC) indicated no adverse events, with similar or improved patient-reported outcomes compared with repairs in the control groups. In 1 study utilizing an innovative delivery technique, a concentrated PRP globule with fibrin matrix was shuttled over a suture to maintain concentrated PRP at the repair site and demonstrated a significant decrease in retears (P = .03) at a 31-month follow-up. A matched-cohort study investigating augmentation with ADSCs demonstrated a significantly lower retear rate in the ADSC-augmented group than the control group at a 28-month follow-up (P < .001). On average, the clinical studies adhered to 66% of relevant MIBO reporting guidelines and had a low risk of bias. Conclusion: Approximately 83% of preclinical studies found a positive biomechanical or histological effect, with no studies showing an overall negative effect. Clinically, utilization of innovative delivery techniques may reduce the risk of arthroscopic washout of PRP and improve retear rates. ADSCs were shown to reduce retear rates at a 28-month follow-up.
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Background: Recurrent tears of the rotator cuff pose a substantial problem despite advances in repair technique. Biologic augmentation via marrow stimulation or vented anchors may strengthen the suture-tendon junction and improve healing rates of native tissue, thereby enhancing outcomes of primary surgical repair. Purpose: To provide a focused systematic review and meta-analysis of local, intraoperative marrow-derived augmentation techniques in clinical primary rotator cuff repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of PubMed, Embase, and Cochrane was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 2131 studies from 2010 to 2022, focused on either marrow stimulation or vented anchors, were isolated and classified as either preclinical or clinical. Meta-analysis was performed for comparative marrow stimulation and vented anchor studies. Heterogeneity was tested through calculation of I 2. Results: A total of 13 clinical studies were included in the review. All 9 comparative studies included in the meta-analysis demonstrated high methodologic quality or a low risk of bias. The pooled retear rate across all 9 clinical studies for patients undergoing marrow stimulation was 11%. For the 5 studies in the meta-analysis, the pooled retear rates were 15% for marrow stimulation and 30% for controls. Meta-analysis demonstrated a significant difference in the overall retear rate that favored marrow stimulation (odds ratio [OR], 0.41; 95% CI, 0.25-0.66; P = .0003; I 2 = 0%). Similarly, meta-analysis of the Constant score at final follow-up demonstrated a statistically significant difference between the 2 groups that favored a higher Constant score in the marrow stimulation group (mean difference, 2.84; 95% CI, 1.02-4.66; P = .002; I 2 = 29%). Vented anchors demonstrated improved ossification and bone density at the anchor site, but no difference in outcomes or retear. Pooled retear rates were 22.5% for vented anchors and 27.8% for controls. Conclusion: Current evidence demonstrates that marrow-stimulation techniques may have a positive impact on healing and retear rate, while vented anchors have a muted impact relative to nonvented anchors. Although available evidence is limited and more research is needed, findings to date suggest that marrow stimulation techniques may be an inexpensive, straightforward technique to consider in qualifying patients to prevent rotator cuff retears.
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Background: Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer. Results: A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%. Discussion and Conclusion: A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.
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INTRODUCTION: The primary purpose of this study was to determine the number of patients who would be denied a complication-free total shoulder arthroplasty (TSA) based on implementation of body mass index (BMI) eligibility cutoffs. METHODS: The National Surgical Quality Improvement Program database was queried to identify all patients who underwent primary TSA. Patient demographics and 30-day postoperative complications were compared according to BMI stratification using the Pearson chi-square test and binary logistic regression analysis adjusted for age and modified Charlson comorbidity index. A BMI eligibility criterion of ≥40 kg/m2 was used to calculate the positive predictive value (PPV) to assess the number of complication-free TSAs that would be denied to avoid a complication in a single patient. RESULTS: A total of 23,284 patients who underwent TSA met inclusion criteria. The overall complication rate was 7.2%. Using a BMI cutoff of ≥40 kg/m2 would yield a PPV of 7% for all Major Complications. This means that 14 complication-free procedures would be denied to avoid a Major Complication. In addition, BMI ≥40 kg/m2 served as an independent risk factor for acute renal failure, pulmonary embolism, ventilator use >48 hours, and readmission. The PPV for these clinically significant complications using BMI ≥40 kg/m2 as a cutoff was 4.9%. This translates into 20 patients being denied a complication-free procedure to avoid a single clinically significant medical complication. If this policy was enforced on the 2,426 patients who exceeded BMI ≥40 kg/m2 in this study, nearly 2,307 patients would be denied the potential benefit of surgery to prevent 119 complications. CONCLUSION: The use of eligibility criteria for primary TSA or RSA based solely on BMI threshold values presents a potential limitation in access to care to these patients who otherwise would have a complication-free procedure. LEVEL OF EVIDENCE: Level III, prognostic, retrospective cohort study.
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Artroplastia do Ombro , Artroplastia do Ombro/efeitos adversos , Índice de Massa Corporal , Acessibilidade aos Serviços de Saúde , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: 3D planning software for shoulder arthroplasty recently emerged for aiding in intraoperative determination of native glenoid. These protocols often require increased scan resolution, however, raising the question of an increased prevalence and clinical impact of incidental findings (IFs) from preoperative imaging. METHODS: A retrospective review of preoperative shoulder CT reports was conducted for 333 consecutive patients planning anatomic or reverse total shoulder arthroplasties. Patients with thin-sliced CT scans (1.25 mm) were compared with those with standard CT scans (2.5 mm). Poisson regression was performed with baseline characteristics and potentially pathologic IFs (PPIFs). RESULTS: IFs were present in 131 of the 333 scans (39.3%), and 38 of the 333 scans (11.4%) included PPIFs. Only 8 of the 333 scans (2.4%) required workup, with 2 of the 333 (0.6%) leading to new cancer diagnoses. Thin-sliced CT scans detected a higher mean number of IFs (1.12 versus 0.22, P < 0.001) while the mean number of PPIFs remained similar (0.13 versus 0.10, P = 0.43). CONCLUSION: IFs are frequent; however, only 0.6% scans led to new cancer diagnoses. Comparison of thin-sliced with standard CT scans revealed a higher frequency of IFs but similar PPIFs, indicating increased burden of IFs without the benefit of identifying additional malignancies. As demand rises for shoulder arthroplasties, surgeons should consider the potential hidden costs of IFs when using 3D planning programs.
Assuntos
Artroplastia do Ombro , Artroplastia do Ombro/métodos , Humanos , Achados Incidentais , Prevalência , Escápula , Tomografia Computadorizada por Raios X/métodosRESUMO
Today, the treatment of osteoarthritis in the rotator cuff-deficient population is largely dominated by reverse shoulder arthroplasty (RSA). Despite the popularity of and increased familiarity with this procedure, the complication rate of RSA remains significant. An extended humeral head hemiarthroplasty may provide a less invasive alternative for select patients with cuff tear arthropathy (CTA) and preserved glenohumeral active elevation. With the indications for reverse arthroplasty expanding to younger patients, there are concerns about the longevity of this implant, as well as the associated revision burden. In the setting of failed RSA, the bone stock available for glenosphere baseplate fixation can be inadequate for reimplantation. The treatment strategies for complex shoulder deformities and failed RSA are limited by patient-specific issues, such as anatomy and risk factors. In this review, we discuss the potential role of extended humeral head hemiarthroplasty (CTA hemiarthroplasty) as a primary surgical option in select patients (1) who have preserved elevation > 90°, (2) who have maintained stability (intact coracoacromial ligament), and (3) who desire to circumvent the complications associated with RSA. Furthermore, CTA hemiarthroplasty may be used for severe glenoid erosion, for a fragmented acromion, and in the revision setting for failed RSA aimed at a reliable salvage procedure.
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PURPOSE: The purpose of this study was (1) to assess the flexion initiation test's (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests. METHODS: We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test. RESULTS: Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears. CONCLUSIONS: The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs. LEVEL OF EVIDENCE: Level IV, diagnostic.
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Superior capsule reconstruction (SCR) creates a humeral head depressor in the setting of a massive, irreparable rotator cuff tear. Recently, a 6-mm-thick acellular dermal allograft (ACD) has been shown to be noninferior to the standard fascia lata autograft in recreating native shoulder biomechanics. This paper outlines a reproducible means by which to perform an arthroscopic SCR using a 6-mm ACD. A standard diagnostic arthroscopy first assesses the integrity of the subscapularis and infraspinatus tendons. The glenoid anchors are then placed. Accessory anterior and posterolateral portals are made as well as a lateral portal by which to shuttle the graft. Suture management is paramount. Ideally allograft preparation occurs on the back table simultaneously to maintain efficiency. Suture passage through premade holes in the graft, and when the sutures have passed through and been tensioned, the graft is shuttled into place and tied down with medial and lateral row anchors in SpeedBridge fashion. The thickness of ACD has been shown to influence the ability of the reconstructed superior capsule to perform its role as a humeral head depressor. This technique describes the use of a 6-mm-thick ACD to perform an arthroscopic SCR that minimizes both donor-site morbidity and operative time.
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BACKGROUND: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous. METHODS: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests. RESULTS: The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%. CONCLUSIONS: Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.