Does improved external rotation following reverse shoulder arthroplasty impact clinical outcomes in patients with rotator cuff pathology and external rotation less than 0°?

BACKGROUND: The purpose of this study was to (1) evaluate whether improved external rotation (ER) in patients with preoperative ER <0° impacts their clinical outcomes following reverse shoulder arthroplasty (RSA) for rotator cuff (RC) pathology and (2) describe the differences in preoperative factors and postoperative outcomes in this patient population. Our hypothesis was that clinical outcomes would not be affected by improvement in ER using a lateralized glenosphere design. METHODS: We retrospectively reviewed 55 patients with preoperative ER <0° who underwent primary RSA for RC pathology with lateralized glenosphere. Pre- and postoperative physician-reported ER was blindly measured using a videographic review of patients externally rotating their arm at the side. Patients were evaluated using 5 different patient-reported outcome score thresholds, measured at 12 months postoperatively: (1) minimal clinically important difference (MCID) for American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (ie, ≥20-point increase); (2) MCID for Simple Shoulder Test (SST) scores (≥2.4-point increase); (3) visual analog scale (VAS) for pain score >0; (4) mean ASES score (≥75); and (5) mean SST score (≥6.8), each of which was used to stratify the patients into 2 groups-greater than or equal to vs. less than the threshold. This resulted in 5 different evaluations comparing the 2 groups for any difference in postoperative ER or preoperative factors, including Hamada and Goutallier scores. RESULTS: Regardless of the measured outcome, there was no difference in either postoperative physician- or patient-reported ER between patients who achieved scores higher or lower than the thresholds. Both Hamada and Goutallier score distributions were not different between groups across all the evaluated outcomes. Patients who achieved the MCID for ASES had worse preoperative VAS pain (7 vs. 4, P = .011) and SST (1 vs. 3, P = .020) scores. Across all outcome thresholds, except MCID for SST, pain reduction (ΔVAS) was significantly more pronounced in patients exceeding the thresholds. Improved forward flexion rather than ER was observed in those who achieved the ASES (160° vs. 80°, P = .020) and SST MCIDs (150° vs. 90°, P = .037). Finally, patients who exceeded the thresholds experienced higher satisfaction rates. CONCLUSION: Improvement in ER does not appear to impact patient-reported outcome measures, including ASES and SST in patients with preoperative ER <0° undergoing RSA with a lateralized glenosphere. Patients with more severe pain and worse function at baseline experience less postoperative pain and clinically significant improvement in their reported outcomes.

Randomized Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-Reported Outcomes at Long-Term Follow-Up.

PURPOSE: To evaluate long-term patient-reported outcomes and revision surgery after arthroscopic rotator cuff repair with or without acromioplasty. METHODS: Between 2007 and 2011, prospectively enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears, with any acromial morphology, were randomized into either acromioplasty or nonacromioplasty groups. Patients with revision surgery, subscapularis involvement, advanced neurologic conditions, or death were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of symptomatic retear, revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation were calculated, and t-tests were used to compare outcomes of interest between cohorts. RESULTS: In total, 69 of 90 patients (76.7%) were available at 92.4 months (± 10.5). There were 23 of 32 patients in the acromioplasty cohort and 24 of 37 patients in the nonacromioplasty cohort. Mean age for the nonacromioplasty cohort was 56.9 (± 7.6) years, whereas acromioplasty was 59.6 (± 6.8) years. Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, sex, Workers' Compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g., single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (P = .33), VAS pain (P = 0.79), Constant (P = .17), SST (P = .05), UCLA (P = .19), and Short Form-12 (SF-12) (P = .79) in patients with and without acromioplasty. Two patients with acromioplasty (5.6%) and 3 patients without acromioplasty (9.1%) sustained atraumatic recurrent rotator cuff tear with secondary repair (P = .99), and there was no significant difference in retear rates or patient-reported outcome measures by acromial morphology. CONCLUSIONS: This randomized trial, with mean 7.5-year follow-up, found no difference in validated patient-reported outcomes, retear rate, or revision surgery rate between patients undergoing rotator cuff repair with or without acromioplasty. LEVEL OF EVIDENCE: II, prospective randomized controlled trial.

Bony Ingrowth of Coil-Type Open-Architecture Anchors Compared With Screw-Type PEEK Anchors for the Medial Row in Rotator Cuff Repair: A Randomized Controlled Trial.

PURPOSE: To evaluate outcomes of screw-type and coil-type open-architecture suture anchors with respect to bony ingrowth, release of biological markers, and patient-reported outcome measures when used in rotator cuff repair (RCR). METHODS: Forty patients undergoing arthroscopic RCR for full-thickness rotator cuff tears were enrolled and prospectively randomized to receive a screw-type (19 patients) or coil-type (21 patients) suture anchor for the medial row during repair. All repairs used a transosseous-equivalent configuration with footprint anchors laterally. Marrow elements released during surgery were evaluated for 9 cytokine markers (insulin-like growth factor 1, fibroblast growth factor 2, bone morphogenetic proteins 7 and 2, platelet-derived growth factors AA and BB, epidermal growth factor, transforming growth factor beta1, and vascular endothelial growth factor). Postoperative computed tomography scans were performed at 6 months. Range of motion, strength, and validated patient-reported outcome measures (Simple Shoulder Test, Single Assessment Numeric Evaluation, visual analog scale, and American Shoulder and Elbow Surgeons scores) were gathered before the operation and at 6 months and 1 year postoperatively. RESULTS: Bone mineral density surrounding the coil-type anchor was significantly greater than that surrounding the screw-type anchor (P = .005). Bone mineral density values within the coil-type and screw-type anchors were comparable (P = .527); however, a larger amount of total bone mineral mass (in milligrams) was shown within the coil-type anchor owing to its larger volume (P < .01). Marrow elements released at the repair site were similar between groups (P > .05). Postoperatively, no statistically significant difference was found between groups for clinical outcome measures at 6 months or 1 year. Retear and complication rates were similar between groups (P > .05). CONCLUSIONS: Both the coil-type and screw-type anchors can be reliably used for RCR and produce similar clinical outcomes. The coil-type anchor resulted in superior bony growth surrounding the anchor and a larger total bone mineral mass within the anchor owing to its larger volume. LEVEL OF EVIDENCE: Level II, randomized prospective comparative study.

Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis.

PURPOSE: To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared. RESULTS: A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery. CONCLUSIONS: Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals. LEVEL OF EVIDENCE: Level III, retrospective comparative database study.

Management of Chondral Lesions of the Knee: Analysis of Trends and Short-Term Complications Using the National Surgical Quality Improvement Program Database.

PURPOSE: To provide updated surgical trends of cartilage procedures differentiated by the classic groups of palliative, repair, and restorative modalities. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2010-2016 for the following cartilage procedures: chondroplasty, microfracture, arthroscopic osteochondral autograft or allograft transplantation, open osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Demographic variables and short-term (30-day) complications were analyzed with 1-way analysis of variance and post hoc analysis. Linear regression analysis was performed to analyze trends over time. RESULTS: A total of 15,609 procedures performed between 2010 and 2016 were analyzed. On average, 342.2 ± 27.9 cartilage procedures were performed per 100,000 operations. There was a linear increase in the management of overall cartilage procedures per 100,000 operations (P = .002). There were also linear increases in arthroscopic osteochondral autograft transplantation, arthroscopic osteochondral allograft transplantation, open osteochondral autograft transplantation, open osteochondral allograft transplantation, and autologous chondrocyte implantation (P < .001, P = .037, P = .001, P = .006, and P = .002, respectively). Meniscectomy was the most frequently performed concomitant procedure (9.7%-64.2% of cases). Chondroplasty and microfracture showed no change in frequency over time (P = .140 and P = .720, respectively). The overall complication rate was 2.1% for chondroplasty, 1.4% for microfracture, 1.8% for arthroscopic osteochondral autograft transplantation, 1.0% for arthroscopic osteochondral allograft transplantation, 1.4% for open osteochondral autograft transplantation, 1.1% for open osteochondral allograft transplantation, and 0.75% for autologous chondrocyte implantation. Deep vein thrombosis was the most common complication, occurring in 0.4% to 1.0% of cases. No statistically significant difference was found in complication rates between procedures (P = .105). CONCLUSIONS: Cartilage restoration is becoming an increasingly popular modality to address chondral defects. Minimal complication rates suggest that these procedures may be safely performed concomitantly with other interventions. LEVEL OF EVIDENCE: Level IV, retrospective database analysis.

Operative Time as an Independent and Modifiable Risk Factor for Short-Term Complications After Knee Arthroscopy.

PURPOSE: To determine whether operative time is an independent risk factor for 30-day complications after arthroscopic surgical procedures on the knee. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2005 and 2016 for all arthroscopic knee procedures including lateral release, loose body removal, synovectomy, chondroplasty, microfracture, and meniscectomy. Cases with concomitant procedures were excluded. Correlations between operative time and adverse events were controlled for variables such as age, sex, body mass index, patient comorbidities, and procedure using a multivariate Poisson regression with robust error variance. RESULTS: A total of 78,864 procedures met our inclusion and exclusion criteria. The mean age of patients was 51.0 ± 14.3 years; mean operative time, 31.2 ± 18.1 minutes; and mean body mass index, 31.0 ± 7.8. Arthroscopic lateral release (coefficient, 5.8; 95% confidence interval [CI], 4.8-6.8; P < .001), removal of loose bodies (coefficient, 4.2; 95% CI, 3.2-5.3; P < .001), synovectomy (coefficient, 1.8; 95% CI, 1.2-2.3; P < .001), and microfracture (coefficient, 6.5; 95% CI, 5.8-7.2; P < .001) had significantly greater durations of surgery in comparison with meniscectomy. The overall rate of adverse events was 1.24%. After we adjusted for demographic characteristics and the procedure, a 15-minute increase in operative duration was associated with an increased risk of transfusion (relative risk [RR], 1.5; 95% CI, 1.3-1.8; P < .001), death (RR, 1.6; 95% CI, 1.2-2.1; P = .005), dehiscence (RR, 1.6; 95% CI, 1.2-2.2; P = .002), surgical-site infection (RR, 1.3; 95% CI, 1.2-1.3; P = .001), sepsis (RR, 1.3; 95% CI, 1.2-1.4; P < .001), readmission (RR, 1.1; 95% CI, 1.1-1.2; P < .001), and extended length of stay (RR, 1.4; 95% CI, 1.3-1.4; P < .001). CONCLUSIONS: Marginal increases in operative time are associated with an increased risk of adverse events such as surgical-site infection, sepsis, extended length of stay, and readmission. Efforts should be made to maximize surgical efficiency. LEVEL OF EVIDENCE: Level IV, retrospective database study.

Comparative analysis of work-related outcomes in hemiarthroplasty with concentric glenoid reaming and total shoulder arthroplasty.

BACKGROUND: Anatomic total shoulder arthroplasty (aTSA) has demonstrated high levels of return to work, although there are fears of glenoid component loosening with higher work demand. METHODS: A retrospective query was performed of all patients who received hemiarthroplasty with ream-and-run resurfacing (Hemi RR) between 2005 and 2014. Included patients were matched to an aTSA cohort by age, body mass index, sex, and hand dominance. Preoperative and postoperative work status, by level of duty and occupation, was collected. RESULTS: Twenty-five patients receiving Hemi RR and 28 patients receiving TSA completed this questionnaire (82.8% compliance). Mean follow-up was 69.1 ± 24.8 months. In total, 100% of Hemi RR patients returned to work, and 89.3% of TSA patients returned to work (P = .091). The Hemi RR patients had higher rates of return to work for heavy-duty workers only (7 of 7 vs. 2 of 4, P = .038), although only 1 patient in the TSA group reported failure to work was due to shoulder reasons. Mean duration of return to work was 2.5 ± 4.8 months for patients receiving Hemi RR and 1.98 ± 2.6 months for those receiving TSA (P = .653). CONCLUSIONS: Hemi RR had a high return to heavy-duty work, likely due to fewer surgeon-imposed restrictions. The results of this study may help manage return to work expectations after Hemi RR according to the level of duty and suggest Hemi RR is a viable option for heavy-duty laborers with end-stage glenohumeral arthritis.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.

BACKGROUND: Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty. METHODS: Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. RESULTS: A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). CONCLUSION: The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Establishing clinically significant outcome after arthroscopic rotator cuff repair.

BACKGROUND: Outcomes reporting in rotator cuff repair (RCR) literature has been variable. The minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) bridge the gap between statistical significance and clinical relevance. METHODS: The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (Constant) scores were collected preoperatively and 1 year postoperatively for patients undergoing RCR between 2014 and 2017. An anchor-based approach was used to calculate the MCID, SCB change, and PASS for the ASES questionnaire. RESULTS: The study included 288 patients who underwent RCR. The MCID, SCB, and PASS were, respectively, 11.1, 17.5, and 86.7 for ASES, 4.6, 5.5, and 23.3 for the Constant score, and 16.9, 29.8, and 82.5 for the SANE score. Factors associated with reduced odds of achieving MCID were current smoking for ASES (odds ratio, 0.056) and single-row repair for the Constant score (odds ratio, 0.310). Workers' compensation patients had reduced odds of achieving ASES SCB (odds ratio, 0.267) and were associated with reduced odds of achieving PASS by ASES (odds ratio, 0.244), SANE (OR, 0.452), and Constant (odds ratio, 0.313). Lower preoperative scores were associated with achieving MCID and SCB and higher preoperative Constant scores associated with PASS (P < .001). CONCLUSION: This study establishes MCID, SCB, and PASS for ASES, Constant, and SANE scores in patients undergoing RCR. Factors associated with failing to achieve clinically significant values included current smoking, single-row repairs, high body mass index, and workers' compensation status.

Recurrence Rate of Instability After Remplissage for Treatment of Traumatic Anterior Shoulder Instability: A Systematic Review in Treatment of Subcritical Glenoid Bone Loss.

PURPOSE: To report outcomes after arthroscopic remplissage in patients with anterior shoulder instability and subcritical glenoid bone loss, specifically regarding recurrence of instability, return to sport, and changes in range of motion. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform a search using the PubMed, Embase, Cochrane Library, and Scopus databases. Forest plots were used to evaluate the overall values for recurrent instability, change in external rotation, and return to sport after arthroscopic Bankart repair with or without remplissage. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklist were used to evaluate bias. RESULTS: Twenty-two articles met the inclusion and exclusion criteria. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklists deemed studies as acceptable quality with low bias. Among 694 patients (522 male and 106 female patients) undergoing remplissage, the mean age was 28.3 ± 5.3 years and the mean duration of follow-up was 32.5 ± 13.9 months. The recurrence rate of instability ranged from 0% to 20%. The change in external rotation in 90° of abduction ranged from -11.3° to -1.0°, and the change in external rotation with the arm fully adducted ranged from -8.0° to +4.5°. The overall rate of return to sport ranged from 56.9% to 100% after remplissage. The rate of return to sport at the preinjury level ranged from 41.7% to 100%. In addition, arthroscopic remplissage in addition to Bankart repair had a reduced odds of recurrent instability developing, ranging from 0.07 to 0.88, when compared with isolated Bankart repair. CONCLUSIONS: Arthroscopic remplissage combined with Bankart repair is an effective procedure in the treatment of patients with engaging Hill-Sachs lesions and minimal glenoid bone loss. Patients can expect favorable rates of recurrent instability with a negligible loss of external rotation when compared with isolated Bankart repair. Treatment algorithms may be updated to include this procedure for engaging Hill-Sachs lesions, measuring between 20% and 40% in volume, with subcritical (<20%) glenoid bone loss. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency.

BACKGROUND: Since US Food and Drug Administration approval of the reverse prosthesis in 2003, the incidence of shoulder arthroplasty in the United States has risen dramatically. With increasing demand, efforts have shifted from traditional volume-based health care models to more patient-centered care. The purpose of this systematic literature review is to establish the time point of maximum medical improvement (MMI) following reverse total shoulder arthroplasty (rTSA). MATERIALS AND METHODS: We conducted a systematic review of studies reporting validated patient-reported outcome measures (PROMs) across multiple postoperative time points following rTSA. Established minimal clinically important difference values for PROMs specific to shoulder arthroplasty were used to determine significant clinical improvement. The time point beyond which significant improvement did not occur was established as MMI. RESULTS: MMI occurred at 1 postoperative year following rTSA. When preoperative measures were compared with 1-year postoperative outcomes, all but 1 PROM demonstrated significant clinical improvement (P < .001). There were no significant improvements between any 2 subsequent time points beyond 1 year (P > .050). Range of motion significantly improved between preoperative and 1-year levels (P < .001). No PROMs or range-of-motion parameters significantly improved beyond 1 year (P > .999). CONCLUSIONS: Patients achieved MMI at 1 postoperative year following rTSA. Patients showed rapid improvements in subjective symptoms within the first 3 months and continued to gradually improve until 1 year. Surgeons should counsel patients with these evidence-based expectations for clinical recovery, particularly the time frame of expected improvements in pain, function, and range of motion, as well as risks of and plans of action for postoperative complications.

How many innings can we throw: does workload influence injury risk in Major League Baseball? An analysis of professional starting pitchers between 2010 and 2015.

BACKGROUND: There has been increasing interest regarding the association between pitch counts, as well as total workload per season, and the risk of injury among Major League Baseball (MLB) starting pitchers. METHODS: We used publicly available databases to identify all MLB starting pitchers eligible for play who made at least 5 starts in seasons between 2010 and 2015. For all included pitchers, annual pitching statistics (number of starts, total season pitch counts, total season inning counts, and average pitch count per game started) and annual disabled list (DL) information (time on DL for any reason and time on DL related to upper extremity, lower extremity, or axial body injury) were collected. A multiple logistic regression analyzed games started, pitch counts, innings pitched, and pitches per start during all previous seasons as a risk factor for injury in the current season, controlling for previous injury. RESULTS: A total of 161 starting MLB pitchers met the inclusion criteria. With the exception of total innings pitched from 2010-2011 being significantly associated with DL placement in 2012 (no DL, 310.5 ± 97.5 innings; DL, 344.7 ± 85.9 innings; P = .040), no other finding for starts, pitch counts, innings, or pitches per start in the cumulative years from 2010-2014 had a significant association with pitcher placement on the DL for any musculoskeletal reason or for an upper extremity reason between 2011 and 2015. CONCLUSIONS: In this study, we demonstrate that there is no association between preceding years of cumulative pitches, starts, innings pitched, or average pitches per start and being placed on the DL for any musculoskeletal reason.

Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis.

BACKGROUND: Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. METHODS: Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. RESULTS: The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). DISCUSSION: Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. LEVEL OF EVIDENCE: Level III retrospective cohort.

Magnetic Resonance Imaging Findings of the Asymptomatic Shoulder May Impact Performance, Not Future Injury List Placement in Major League Baseball Pitchers.

Purpose: To evaluate preseason shoulder magnetic resonance images (MRIs) obtained from pitchers entering either major or minor league baseball (MLB) and correlate findings with subsequent injury, operative repair, and placement on the injured list (IL). Methods: Preseason-MRI of the throwing shoulders of professional-level baseball pitchers, taken during routine evaluations at a single organization (2004-2017) were retrospectively reviewed. Publicly available databases were queried to exclude pitchers with known injuries prior to pre-signing imaging. Three blinded reviewers reviewed all MRI scans independently to evaluate for the presence of abnormalities in the rotator cuff (RTC), labrum, capsule, long-head of the biceps tendon (LHBT), and humeral head. Binary imaging findings were correlated to future placement on the IL for subsequent shoulder complaints. Bivariate statistics using Student's t-tests and Fisher exact tests (both α = .05) were used in this study. Results: A total of 38 asymptomatic pitchers with shoulder MRIs were included. Pitchers had a mean (±SD) age of 28.2 ± 4.9 and had pitched an average of 119.6 ± 143.8 career games. Pitchers with partial articular-sided RTC tears (P = .04) or intra-articular BT hyperintensity (P = .04) on preseason MRI demonstrated an association with the need for future surgery. Pitchers with evidence of labral heterogeneity demonstrated greater total career pitch counts (10,034.1 vs 2,465.3; P = .04). Evidence of a posterior-superior humeral cyst was associated with decreased strikeouts per 9 innings (6.1 vs 8.0; P = .039) and total strikeout percentage (16.1% vs 23.2%; P = .04). Conclusion: Although there was a significant difference in the percent of various radiographic findings between the injured and healthy cohort, no MRI findings were predictive of future IL placement or duration of placement. The presence of a posterior superior humeral cyst was associated with decreased strikeout rates at 2 and 3 years, the presence of a labral tear was associated with decreased earned run average (ERA) at 3 years and decreased career strikeout percentages, and increased capsular signal was associated with decreased 5-year ERA. Level of Evidence: Level IV, retrospective study.

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor.

PURPOSE: To describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing. METHODS: This study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed. RESULTS: This study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%). CONCLUSIONS: Arthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Effect of Triangulation Simulator Training on Arthroscopy Skills: A Prospective Randomized Controlled Trial.

PURPOSE: To prospectively evaluate the transferability of skills acquired on a low-cost, at-home, nonanatomic triangulation simulation system to cadaveric models. METHODS: We randomized 28 medical students into either a simulator-training group (n = 14) or group with no training (control, n = 14). All subjects were pretested using a standardized checklist of arthroscopic skills on cadaveric knees and shoulders. Training-group subjects practiced on the triangulation simulator for 90 minutes per week for 4 consecutive weeks. Control subjects received no training. All subjects completed a post-test checklist of arthroscopic skills on cadaveric knees and shoulders, as well as 4 training tasks on the simulator. A blinded orthopaedic surgeon evaluated the arthroscopic videos using the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score. RESULTS: Training-group knee and shoulder ASSET scores increased from 12.2 ± 1.85 to 14.6 ± 2.76 (P = .02) and from 14.6 ± 3.5 to 17.9 ± 4.5 (P = .29), respectively. In the control group, knee and shoulder ASSET scores increased from 14.3 ± 3.12 to 14.25 ± 4.67 (P = .99) and from 14.2 ± 2.7 to 17.07 ± 6.7 (P = .58), respectively. There were no significant differences in the mean post-test ASSET scores between the training group and control group for either knee or shoulder arthroscopy. The post-test ASSET safety subscore during knee arthroscopy was significantly higher in the training group (P = .03). The training group was able to complete significantly more simulator tasks compared with controls (P = .003) at post-testing. A significant positive correlation was found between knee arthroscopy performance and the number of tasks completed during simulation post-testing (P = .043). There was no significant correlation between shoulder arthroscopy performance and simulation performance (P = .532). CONCLUSIONS: Basic triangulation skills may be acquired by training on a low-cost, at-home, nonanatomic triangulation simulation system, although the degree of transferability and universal joint applicability, as well as the existence of an early ceiling effect in skill development, could not be shown. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Accuracy of patient-specific instrumentation in shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: There has been significant recent emphasis on the use of patient-specific instrumentation (PSI) in shoulder arthroplasty. However, clinical data are lacking to support the increased time and expense associated with PSI. Our purposes were to determine whether PSI significantly improves implantation accuracy during total shoulder arthroplasty (TSA) and to analyze available techniques and correlation with clinical outcomes. We hypothesized that PSI may improve glenoid component position radiographically but without correlation with clinical outcomes. METHODS: The MEDLINE, Scopus, Embase, and Cochrane Library databases were queried. Included articles reported use of any preoperative or intraoperative PSI techniques, models, or guides to assist with TSA prosthesis implantation. The primary outcomes were mean deviation from the preoperative plan in version (in degrees), inclination (in degrees), and entry-point offset on the glenoid (in millimeters). RESULTS: Among the included articles, 518 TSA procedures (352 anatomic and 166 reverse) were performed. The mean postoperative errors in both version and inclination angles were 5° or less in 20 articles (90.9%) using PSI. Meta-analysis revealed no statistically significant differences in version error (P > .999, I 2 = 64.6%), inclination error (P = .702, I 2 = 82.2%), or positional offset (P = .777, I 2 = 85.7%) between PSI and standard instrumentation. No data regarding patient-reported outcome measures, range of motion, strength, or glenoid component loosening and longevity were reported. CONCLUSIONS: Meta-analysis revealed no significant differences in accuracy between PSI and standard instrumentation. Although PSI may possess the potential to improve TSA techniques, further investigations regarding long-term clinical outcomes, impact on operating room time, and cost-effectiveness are warranted before PSI can be routinely recommended over conventional instrumentation.

Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis.

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, -2.4±5.0 vs -2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 2019; 42(5):276-284.].

Figure-of-eight Reconstruction of the Sternoclavicular Joint: Outcomes of Sport and Work.

Instability of the sternoclavicular joint is a challenging condition given the proximity of neurovascular structures and minimal osseous constraint, and little is known regarding return to activity. A prospectively maintained institutional registry was retrospectively queried for all sternoclavicular joint reconstructions performed from 2005 to 2016. All included patients were asked to answer questions from a previously established survey to assess return to sport, work, and satisfaction following surgery. Ten patients (12 shoulders) were available for long-term follow-up (71.4%; range, 26-145 months). There were significant improvements in both visual analog scale (-2.3±3.0) and American Shoulder and Elbow Surgeons (+29.7±29.6) scores (P<.001, respectively). Seven patients reported good to excellent satisfaction, and all patients reported they would undergo the surgery again in hindsight. Regarding sports, 4 of 9 (44.4%) were able to return to sport, 1 of 9 (11.1%) was able to return to same or better intensity, and 4 of 8 (50%) were able to perform a push-up having done so prior to injury. In total, 3 of 7 (42.9%) returned to work, with 1 of 7 (14.3%) returning to same or better intensity. None of the heavy-duty workers were able to return to their preinjury level of duty. Although figure-of-eight reconstruction of the sternoclavicular joint provides consistent clinical improvement and acceptable levels of patient satisfaction, most patients were unable to return to preinjury activity. Patients should be counseled preoperatively regarding appropriate expectations. Workers with strenuous responsibilities should be advised to find alternative employment opportunities. [Orthopedics. 2019; 42(4):205-210.].

Novel 3-dimensionally printed patient-specific guide improves accuracy compared with standard total shoulder arthroplasty guide: a cadaveric study.

BACKGROUND: Patient-specific instrumentation (PSI) systems for total shoulder arthroplasty (TSA) can improve glenoid component placement, but may involve considerable expense and production delays. The purpose of this study was to evaluate a novel technique for in-house production of 3-dimensionally printed, patient-specific glenoid guides. We hypothesized that our PSI guide would improve the accuracy of glenoid guide pin placement compared with a standard TSA guide. METHODS: We randomized 20 cadaveric shoulders to receive pin placement via the PSI guide (n = 10, study group) or standard TSA guide (n = 10, control group). PSI guides were designed to fit each glenoid based on 3-dimensional scapular models constructed from computed tomography scans. A presurgical plan was created for the guide pin trajectory in neutral version and inclination based on individual scapular anatomy. After pin placement, 3-dimensional models from repeated computed tomography scans were superimposed to calculate deviation from the presurgical plan for each specimen. RESULTS: Inclination deviation was significantly lower in the PSI group than in the standard guide group (1.5° ± 1.6° vs. 6.4° ± 5.0°, P = .009). The glenoid entry site exhibited significantly less deviation in the PSI group (0.8 ± 0.6 mm vs. 2.1 ± 1.2 mm, P = .008). The average production cost and time for the PSI guides were $29.95 and 4 hours 40 minutes per guide, respectively. CONCLUSIONS: The PSI guide significantly improved the accuracy of glenoid pin placement compared with the standard TSA guide. Our PSI guides can be produced in-house, inexpensively, and with substantially reduced time compared with commercially available guides.