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

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

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

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

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

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

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

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

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

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

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

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

Recent trends in Medicare utilization and surgeon reimbursement for shoulder arthroplasty.

BACKGROUND: Recent efforts to contain health care costs and move toward value-based health care have intensified, with a continued focus on Medicare expenditures, especially for high-volume procedures. As total shoulder arthroplasty (TSA) volume continues to increase, especially within the Medicare population, it is important for orthopedic surgeons to understand recent trends in the allocation of health care expenditures and potential effects on reimbursements. The purpose of this study was to evaluate trends in annual Medicare utilization and provider reimbursement rates for shoulder arthroplasty procedures between 2012 and 2017. METHODS: This study tracked annual Medicare claims and payments to shoulder arthroplasty surgeons via publicly available databases and aggregated data at the county level. Descriptive statistics were used to evaluate trends in procedure volume, utilization rate (per 10,000 Medicare beneficiaries), and reimbursement rate. We used adjusted multiple linear regression models to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percentage Medicare population, and race and ethnicity demographics) and procedure volume, utilization rate, and reimbursement rate. RESULTS: Between 2012 and 2017, there was an 81.3% increase in primary TSA volume and 55.5% increase in primary TSA utilization. The Midwest and South had higher utilization rates than the Northeast and West (P < .001). TSA utilization rates in metropolitan areas were significantly higher than in rural areas (P < .001). Utilization rates for primary TSA procedures also had a significant negative association with poverty rate (P < .001). Regarding reimbursements, the Medicare payment per TSA case decreased from 2012 to 2017, with overall inflation-adjusted decreases of 7.1% and 11.8% for primary and revision cases, respectively. TSAs performed in metropolitan areas received significantly higher reimbursements per case than TSAs performed in rural areas ($1108.05 and $1066.40, respectively; P = .002). Furthermore, reimbursements per case were on average higher in the Northeast and West than in the South and Midwest (P < .001). CONCLUSIONS: Our study confirms that although TSA volume and per capita utilization have increased dramatically since 2012, Medicare Part B reimbursements to surgeons have continued to fall even after the adoption of bundled-payment models for orthopedic procedures. Cost-containment efforts continue to focus on Medicare reimbursements to surgeons, although other expenditures such as hospital payments and operational and implant costs must also be evaluated as part of an overall transition to value-based health care.

Statistical fragility of randomized clinical trials in shoulder arthroplasty.

BACKGROUND: The P value is a statistical tool used to assess the statistical significance of clinical trial outcomes in orthopedic surgery. However, the P value does not evaluate research quality or clinical significance. The Fragility Index (FI) is an alternative statistical method that can be used to assess the quality and significance of clinical research and is defined as the number of patients in a study intervention group necessary to convert an outcome from statistically significant to statistically insignificant or vice versa. The primary purpose of this study was to evaluate the statistical robustness of clinical trials regarding shoulder arthroplasty using the FI. The secondary goal was to identify trial characteristics associated greater statistical fragility. METHODS: A systematic review of randomized clinical trials in shoulder arthroplasty was performed. The FI was calculated for all dichotomous, categorical study outcomes discussed in the identified studies. Descriptive statistics and the Pearson correlation coefficient were used to evaluate all studies and characterize associations between study variables. RESULTS: A total of 13 randomized controlled trials were identified and evaluated; these trials had a median sample size of 47 patients (mean, 54 patients; range, 26-102 patients) and a median of 7 patients (mean, 5.8 patients; range, 0-14 patients) lost to follow-up. The median FI was 6 (mean, 5; range, 1-11), a higher FI than what has been observed in other orthopedic subspecialties. However, the majority of outcomes (74.4%) had an FI that was less than the number of patients lost to follow-up, and most outcomes (89.7%) were statistically insignificant. CONCLUSION: Randomized controlled trials in shoulder arthroplasty have comparable statistical robustness to the literature in other orthopedic surgical subspecialties. We believe that the inclusion of the FI in future comparative studies in the shoulder arthroplasty literature will allow surgeons to better assess the statistical robustness of future research.

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

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

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

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

The impact of age on 30-day complications following shoulder instability surgery.

HYPOTHESIS: The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery. METHODS: Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis. RESULTS: Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for <25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P < .001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P < .001), and 30-day readmission (OR 3.39; P = .013). CONCLUSION: This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Is surgical duration associated with postoperative complications in primary shoulder arthroplasty?

BACKGROUND: Surgical duration is an independent predictor of short-term adverse outcomes after a variety of orthopedic procedures, both arthroscopic and open. However, this association in shoulder arthroplasty remains unclear. The purpose of this study was to identify the association between surgical duration and postoperative complications, as well as increased use of health care resources, after shoulder arthroplasty. METHODS: Primary shoulder arthroplasty procedures performed from 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgical duration was divided into 3 cohorts: (1) surgical procedures lasting less than 90 minutes, (2) those lasting between 90 and 120 minutes, and (3) those lasting more than 120 minutes. Baseline patient characteristics and outcome variables were compared using bivariate analysis. Outcome variables were compared using multivariate analysis. RESULTS: Overall, 14,106 patients were identified. Longer surgical duration was significantly associated with younger age, male patients, higher body mass index, and use of general anesthesia, (P < .001 for each), as well as smoking history (P < .39). Relative to operative times shorter than 90 minutes, surgical procedures lasting more than 120 minutes had higher rates of any complication (P = .002), return to the operating room (P = .008), urinary tract infection (P = .02), non-home discharge (P < .001), blood transfusion (P < .001), and unplanned 30-day hospital readmission (P = .03). CONCLUSION: Increasing surgical duration was associated with a variety of postoperative medical complications and increased use of health care resources including discharge to acute care facilities, blood transfusions, and hospital readmission. These data suggest that surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Short-term outcomes associated with drain use in shoulder arthroplasties: a prospective, randomized controlled trial.

BACKGROUND: This study examined the immediate outcomes during the perioperative period associated with drains in the setting of total shoulder arthroplasty or reverse shoulder arthroplasty. We hypothesized that drain use would result in lower postoperative hemoglobin and hematocrit levels that would increase transfusion rates and longer hospital stays that would increase hospital costs. METHODS: The study prospectively randomized 100 patients (55% women; average age, 69.3 years) who underwent total shoulder arthroplasty or reverse shoulder arthroplasty to receive a closed-suction drainage device (drain group, n = 50) or not (control group, n = 50) at the time of wound closure. Basic demographic information and intraoperative and postoperative data were collected. RESULTS: The groups were similar with respect to basic patient demographics. Postoperatively, drains had no effect on transfusion rates or any perioperative complication (P > .715). There were also no significant differences in hemoglobin or hematocrit levels immediately after surgery or on postoperative day 1. On average, patients were discharged from the hospital 1.6 days and 2.1 days postoperatively in the control and drain groups, respectively (P = .124). The average cost associated for the control cohort's hospital stay was $35,796 ± $13,078 compared with $43,219 ± $24,679 for the drain cohort (P = .063). DISCUSSION: Drain use after shoulder arthroplasty had no appreciable difference on short-term perioperative outcomes, postoperative anemia, length of hospital stay, or cost. It is possible that the potential negative effects of postoperative drainage are blunted by the routine use of tranexamic acid.

Elbow Arthroscopy: 30-Day Postoperative Complication Profile and Associated Risk Factors.

PURPOSE: To analyze (1) the incidence and type of complications after elbow arthroscopy, (2) the incidence of returning to the operating room (OR) after elbow arthroscopy, and (3) patient and risk factors for complications across a national surgical outcome database. METHODS: Patients who underwent elbow arthroscopy from January 2005 through December 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database by use of Current Procedural Terminology codes. Basic patient demographic data and medical comorbidities were recorded. Postoperative adverse events and a return to the OR occurring within 30 days after the index procedure were identified, and patient and procedural risk factors were investigated. RESULTS: Five hundred thirty elbow arthroscopy cases were available for analysis. The aggregate rate of 30-day adverse events was 2.83%, whereas the rate of any patient having an adverse event was 1.89%. The most common adverse event was deep infection (0.57%). Univariate analyses showed that renal disease, preoperative steroid use, higher American Society of Anesthesiologists (ASA) class, and preoperative diagnosis were associated with the occurrence of an adverse event. Multivariate analyses showed that increasing ASA class, specifically ASA class 3 and class 4, was an independent predictor of a postoperative adverse event. Furthermore, 0.94% of cases required a return to the OR. Univariate analyses showed that preoperative steroid use and diagnosis of trauma were associated with a return to the OR. These findings were confirmed by multivariate analyses. CONCLUSIONS: Overall, the incidence of 30-day postoperative adverse events (1.89%) and need to return to the OR (0.94%) is low. Increased ASA class is an independent risk factor for the occurrence of a postoperative adverse event; preoperative steroid use and diagnoses relating to a traumatic or inflammatory cause are predictive of the need to return to the OR. These results can assist surgeons in patient selection, preoperative optimization, and preoperative risk stratification. LEVEL OF EVIDENCE: Level IV, case series.

Management of Failed Shoulder Surgery.

The popularity of shoulder surgery has increased in the past several decades, which has resulted in a concomitant increase in the number of complications that occur in patients who undergo shoulder surgery. Surgeons should understand the complications that may occur in patients who undergo common shoulder procedures. A plan for the management of shoulder surgery complications is necessary regardless whether a surgeon is an expert shoulder surgeon or a novice shoulder surgeon.

Outcomes of lesser tuberosity osteotomy in revision anatomic shoulder arthroplasty.

BACKGROUND: Lesser tuberosity osteotomy (LTO) is a common surgical approach during anatomic shoulder arthroplasty. Outcomes of LTO have been shown to be similar to subscapularis tenotomy and peel techniques, but little is known about the outcomes of LTO during revision arthroplasty. METHODS: This retrospective case series included 10 consecutive patients who underwent LTO during revision shoulder arthroplasty at a single institution from 2012 to 2016. Patients underwent a preoperative computed tomography scan to evaluate the lesser tuberosity bone stock. Demographic information, radiographic evidence of LTO healing, outcomes of range of motion, subscapularis strength, and visual analog scale pain scores were analyzed. RESULTS: Revision total shoulder arthroplasty with LTO was performed for glenoid arthritis after hemiarthroplasty in 10 patients. Average age at surgery was 59.8 years, and no humeral stems were revised. Eight of 10 patients had prior subscapularis tenotomy. Average follow-up after revision surgery was 9.2 months. LTO union was documented in 80% and nondisplaced nonunion in 20%. At follow-up, 50% reported mild pain. Subscapularis strength testing was graded normal in 80% and weak in 20%. Average visual analog scale pain improved from 9.4 prerevision to 4.8 postrevision (P < .05). On average, range of motion improved in active forward elevation from 123° to 141° and remained unchanged in active external rotation from 42° to 42°. CONCLUSION: Patients undergoing LTO during revision anatomic shoulder arthroplasty demonstrate successful LTO bony healing, improvement in pain, and improved forward elevation. In select patients not requiring humeral stem revision, LTO is a safe and effective surgical approach to subscapularis management during revision anatomic shoulder arthroplasty.

Glenoid component loosening associated with increased critical shoulder angle at midterm follow-up.

BACKGROUND: Glenoid component loosening is a common failure mode of total shoulder arthroplasty (TSA). A larger critical shoulder angle (CSA) may cause superior glenoid component loading and more rapid component loosening. The purpose of this study was to define the relationship between the CSA and glenoid component loosening in midterm follow-up after TSA. METHODS: We conducted a retrospective study of 61 primary TSAs for osteoarthritis with an average follow-up of 5.0 ± 2.2 years without surgical revision. Standard true anteroposterior radiographs postoperatively and at longest follow-up were graded in a blinded and repetitive nature for pegged glenoid radiolucent lines and measured for the CSA. An "at-risk" glenoid was defined as grade 3 or higher lucency. RESULTS: The average CSA was 32° ± 5°, median midterm lucency grade was 2 (range, 0-5), and median progression of lucency grade was 1 (range, -1 to 4). At midterm follow-up, 20% of TSAs were grade 3 or higher mean glenoid lucency, with an average CSA of 36°. There was a statistically significant correlation between CSA and both glenoid lucency grade (odds ratio, 1.20 per degree CSA) and progression of lucency grade (odds ratio, 1.24). An increase in CSA of 10° was associated with a 6.2-fold increased odds of having an at-risk glenoid. CONCLUSION: This study identifies the CSA as a risk factor for glenoid component loosening after TSA. Our findings suggest that the CSA may be a modifiable factor during surgery to improve glenoid component outcomes.

Determining glenoid component version after total shoulder arthroplasty.

BACKGROUND: Glenoid component loosening after total shoulder arthroplasty (TSA) may occur if retroversion is not corrected to <10°. However, accurately measuring postoperative glenoid component version has been difficult without postoperative computed tomography (CT), adding cost and radiation exposure outside of the standard radiographic follow-up. We present a new method to assess glenoid component version after TSA using only routine preoperative CT and postoperative radiographs (x-rays). METHODS: Preoperative glenoid version was measured using established methods with an axillary x-ray, 2-dimensional CT, and Glenosys software (Imascap, Plouzané, France). Postoperative glenoid component version and inclination were measured for 61 TSA patients using Mimics software (Materialise, Leuven, Belgium) with preoperative CT and postoperative x-rays. Four patients also had postoperative CTs. Glenoid implantation and imaging were performed on 14 cadavers, allowing validation of results against the gold standard postoperative CT glenoid retroversion measurement. RESULTS: Compared with the gold standard, retroversion and inclination measurement error was 2° ± 1° and 2° ± 1°, respectively. Average postoperative version correction was 6° ± 7°, with 35 of 61 patients (57%) corrected to <10° of retroversion. Correlation between preoperative version measurement methods was good to very good, except on the axillary x-ray. Patients not corrected to <10° of retroversion had significantly higher preoperative retroversion (14° ± 6°) than those corrected to <10° (6° ± 7°; P < .00001). CONCLUSIONS: Glenoid component retroversion after TSA can be accurately measured with a method using only routine preoperative CT and postoperative x-rays, validated to within 1.9° of the gold standard postoperative CT measurement. Future studies using this method may correlate glenoid retroversion correction with glenoid component longevity to help optimize shoulder arthroplasty outcomes.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics.

PURPOSE: To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics. METHODS: Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites. RESULTS: Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 ± 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 ± 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications. CONCLUSIONS: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.