The analgesic effect of ultrasound-guided cervical erector spinae block in arthroscopic shoulder surgery: a randomized controlled clinical trial.

BACKGROUND: Erector spinae plane block (ESPB) is a novel fascial plane block technique that can provide effective perioperative analgesia for thoracic, abdominal and lumbar surgeries. However, the effect of cervical ESPB on postoperative analgesia after arthroscopic shoulder surgery is unknown. The aim of this study is to investigate the analgesic effect and safety of ultrasound-guided cervical ESPB in arthroscopic shoulder surgery. METHODS: Seventy patients undergoing arthroscopy shoulder surgery were randomly assigned to one of two groups: ESPB group (n = 35) or control group (n = 35). Patients in the ESPB group received an ultrasound-guided ESPB at the C7 level with 30 mL of 0.25% ropivacaine 30 min before induction of general anesthesia, whereas patients in the control group received no block. The primary outcome measures were the static visual analogue scale (VAS) pain scores at 4, 12, and 24 h after surgery. Secondary outcomes included heart rate (HR) and mean arterial pressure (MAP) before anesthesia (t1), 5 min after anesthesia (t2), 10 min after skin incision (t3), and 10 min after extubation (t4); intraoperative remifentanil consumption; the Bruggrmann comfort scale (BCS) score, quality of recovery-15 (QoR-15) scale score and the number of patients who required rescue analgesia 24 h after surgery; and adverse events. RESULTS: The static VAS scores at 4, 12 and 24 h after surgery were significantly lower in the ESPB group than those in the control group (2.17 ± 0.71 vs. 3.14 ± 1.19, 1.77 ± 0.77 vs. 2.63 ± 0.84, 0.74 ± 0.66 vs. 1.14 ± 0.88, all P < 0.05). There were no significant differences in HR or MAP at any time point during the perioperative period between the two groups (all P > 0.05). The intraoperative consumption of remifentanil was significantly less in the ESPB group compared to the control group (P < 0.05). The scores of BCS and QoR-15 scale were higher in the ESPB group 24 h after surgery than those in the control group (P < 0.05). Compared to the control group, fewer patients in the ESPB group required rescue analgesia 24 h after surgery (P < 0.05). No serious complications occurred in either group. CONCLUSIONS: Ultrasound-guided cervical ESPB can provide effective postoperative analgesia following arthroscopic shoulder surgery, resulting in a better postoperative recovery with fewer complications. TRIAL REGISTRATION: Chictr.org.cn identifier ChiCTR2300070731 (Date of registry: 21/04/2023, prospectively registered).

Preoperative Rank of Expectations for Shoulder Surgery (PRESS): a novel survey.

BACKGROUND: Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. METHODS: The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of 8 common expectations for elective shoulder surgery by importance and a 0%-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function 7a version 1.0 (PROMIS PF), and PROMIS Pain Interference short form 8a version 2.0 (PROMIS PI) surveys. Patient-reported outcome measure (PROM) surveys were administered 6 months postoperatively. RESULTS: Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete activities of daily living and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients who ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, whereas patients with instability were less satisfied. CONCLUSION: The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore, the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

A Systematic Review of Distinction of Colonization and Infection in Studies that Address C. Acnes and Shoulder Surgery.

BACKGROUND: After shoulder surgery, infection is often diagnosed in the absence of an inflammatory host response (purulence, sepsis). In the absence of inflammation, the more appropriate diagnoses may be colonization or contamination. We reviewed the available data regarding culture of Cutibacterium Acnes during primary and revision shoulder surgery and asked; 1. What is the prevalence of air, skin, and deep tissue colonization? 2. How often is an inflammatory host response associated with diagnosis of postoperative shoulder infection diagnosed on the basis of culture of C. Acnes? 3. Is there any relation between culture of C. Acnes and outcomes of shoulder surgery? METHODS: Three databases were searched for studies that address C. Acnes and colonization or infection related to shoulder surgery. We analyzed data from 80 studies addressing the rates of C. Acnes colonization/infection in patients undergoing shoulder surgery, evidence of an inflammatory host response, and relationship of C. Acnes culture to surgery outcomes. RESULTS: C. Acnes is often cultured in the air in the operating room (mean 10%), the skin before preparation (mean 47%), and deep tissue in primary shoulder arthroplasty (mean 29%), arthroscopy (mean 27%), and other shoulder surgery (mean 21%). C. Acnes was cultured from a mean of 39% of deep tissue samples during revision arthroplasty. C. Acnes was believed to be the causative organism of a high percentage of the infections diagnosed after surgery, 39% in primary shoulder arthroplasties, 53% in revisions, 55% in arthroscopic surgeries, and 44% in a mixture of shoulder surgeries. Infection was nearly always diagnosed in the absence of an inflammatory host response. Documented purulence and sepsis were not specifically ascribed to C. Acnes (rather than more virulent organisms such as S. Aureus). Diagnosis of infection, or unexpected positive culture, with C. Acnes during shoulder surgery is associated with outcomes comparable to shoulders with no bacterial growth. CONCLUSIONS: The evidence to date supports conceptualization of C. Acnes as a common commensal (colonization), and perhaps a frequent contaminant, and an uncommon cause of an inflammatory host response (infection). This is supported by the observations that 1) Unexpected positive culture for C. Acnes is not associated with adverse outcomes after shoulder surgery, and 2) Diagnosed infection with C. Acnes is associated with outcomes comparable to non-infected revision shoulder arthroplasty. We speculate that diagnosis of C. Acnes infection might represent an attempt to account for unexplained discomfort, incapability or stiffness after technically sound shoulder surgery. If so, the hypothesis that stiffness and pain are host responses to C. Acnes needs better experimental support.

Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies.

BACKGROUND: The effect of tranexamic acid (TXA) has been proven to be effective in reducing blood loss in lower limb arthroplasty. The aim of this study is to investigate the effect of TXA in shoulder surgery with the updated studies. MATERIALS AND METHODS: A systematic review and meta-analysis of all the randomized controlled trials were conducted. We compared the outcomes of patients with and without TXA. The PubMed, MEDLINE, EMBASE, and CENTRAL databases were systematically searched for relevant studies. RESULTS: A total of 14 studies, enrolling 1131 patients, were included for qualitative and quantitative analysis. Our results revealed that TXA was associated with a significant reduction in total volume blood loss (mean difference [MD]: -112.97, P = .0006), drain output (MD: -81.90, P < .00001), hemoglobin changes (MD: -0.55, P = .02), shorter operative time (MD: -6.19, P = .01), and lower risk of hematoma formation (odds ratio: -0.20, P = .01). The postoperative visual analog scale pain score was also significantly better in the TXA group (MD: -0.78, P < .00001). No significant difference was detected in length of hospital stay and incidence of thromboembolization. CONCLUSION: The usage of TXA in shoulder surgery appeared to be safe and effective in reducing blood loss without any significant complication.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up.

BACKGROUND: Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up. METHODS: A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up. RESULTS: A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different. CONCLUSION: This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review.

BACKGROUND: Correction of glenoid retroversion is commonly performed in anatomic total shoulder arthroplasty (TSA) to increase component contact area and decrease eccentric loading of the glenoid component. Despite demonstrated biomechanical advantages, limited information exists on the clinical benefit of correcting glenoid retroversion. The purpose of this systematic review is to critically evaluate the existing literature on the effect of preoperative and postoperative glenoid retroversion on clinical functional and radiologic outcomes in patients who underwent anatomic TSA. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, Embase, and Cochrane Library evaluating the impact of glenoid retroversion on clinical and radiologic outcomes of TSA. English-language studies of level I through IV evidence were included. Blinded reviewers conducted multiple screens and methodological quality was appraised using the Modified Coleman Methodology Score. RESULTS: Sixteen studies, including 3 level III and 13 level IV studies (1211 shoulders), satisfied all inclusion criteria. To address glenoid retroversion, 9 studies used corrective reaming techniques, and 4 studies used posteriorly augmented glenoids. Two studies used noncorrective reaming techniques. Mean preoperative retroversion ranged from 12.7° to 24° across studies. Eleven studies analyzed the effect of glenoid retroversion on clinical outcomes, including patient-reported outcome scores (PROs), range of motion (ROM), or clinical failure or revision rates. Most studies (8 of 11) did not report any significant association of pre- or postoperative glenoid retroversion on any clinical outcome. Of the 3 studies that reported significant effects, 1 study reported a negative association between preoperative glenoid retroversion and PROs, 1 study reported inferior postoperative abduction in patients with postoperative glenoid retroversion greater than 15°, and 1 study found an increased clinical failure rate in patients with higher postoperative retroversion. Ten studies reported radiographic results (medial calcar resorption, Central Peg Lucency [CPL] grade, Lazarus lucency grade) at follow-up. Only 1 study reported a significant effect of pre- and postoperative retroversion greater than 15° on CPL grade. CONCLUSION: There is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND: In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS: White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS: A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION: Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

Racial and Ethnic Disparity in Shoulder Surgery: A Systematic Review.

BACKGROUND: Healthcare disparity exists in utilization and delivery of musculoskeletal care and continues to be an obstacle for orthopedic healthcare providers to mitigate. Racial and ethnic disparities exist within various surgical fields including orthopedic surgery and are expected to continue to rise in upcoming years. The aim of this systematic review is to analyze the racial and ethnic disparities on utilization and outcomes after common shoulder surgical procedures. QUESTIONS/PURPOSE: Are there racial or ethnic disparities in outcomes and utilization of shoulder surgeries? Is there evidence to explain the etiology underlying the differences in outcomes among racial and ethnic groups after shoulder surgery? PATIENTS/METHODS: A primary literature search was performed using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases using comprehensive Medical Subject Headings and subject-heading search terms. Studies were included if they reported utilization and or outcomes across two or more racial/ethnic groups in patients (age >16) who underwent shoulder arthroplasty (TSA), rotator cuff repair (RCR), arthroscopic Bankart repair (ABR), Latarjet (LP) and internal fixation (ORIF) of PHF. Baseline demographics, data on procedure utilization, perioperative measures including mortality, operative time, length of stay (LOS), readmission and complications were extracted from included studies, and descriptive statistical analysis performed. RESULTS: Eighteen studies were identified for full text review of which 13 found race and ethnicity as factors affecting utilization and outcomes in TSA, RCR, ABR, LP and ORIF of PHF. Compared to White patients, Black patients were found to have decreased utilization, longer LOS, and greater operative time and mortality after TSA; Black patients also had longer operative times and time to discharge, and lower levels of reported satisfaction after RCR. Hispanic/Latino ethnicity was reported as an independent risk factor for post operative falls following TSA. Hispanic/Latino and Black patients have a higher risk of delayed surgery and greater risk of readmission after surgical treatment of PHF compared to patients of White race. CONCLUSION: This systematic review highlights the limited literature reporting the existence of racial and ethnic disparities in utilization and outcomes after common shoulder surgical procedures. Additionally, there is paucity of studies exploring the underlying etiology of racial and ethnic disparity in outcomes after shoulder surgery. More research is necessary to pave the way for evidence-based action plans to mitigate healthcare disparities after shoulder surgeries, but this review serves as a baseline for where efforts in direct improvement can begin.

Mid-term outcomes of microfracture for the treatment of focal, full-thickness cartilage defects isolated to the humeral head.

BACKGROUND: While microfracture has been shown to be an effective treatment for chondral lesions in the knee, evidence to support its use for chondral defects in the shoulder is limited to short-term outcomes studies. The purpose of this study is to determine if microfracture provides pain relief and improved shoulder function in patients with isolated focal chondral defects of the humeral head at a minimum 5-year follow-up. METHODS: Patients who underwent microfracture procedure for isolated focal chondral defects of the humeral head with a minimum follow-up of 5 years between 02/2006 and 08/2016 were included. At minimum 5-year follow-up, pre- and postoperative patient-reported outcome (PRO) measures were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), Visual Analog Scale (VAS) for pain, and patient satisfaction level (1 = unsatisfied, 10 = very satisfied). Demographic, injury, and surgical data were retrospectively reviewed. Surgical failure was defined as revision surgery for humeral chondral defects or conversion to arthroplasty. Kaplan-Meier analysis was performed to determine survivorship at 5 years. RESULTS: A total of 17 patients met inclusion/exclusion criteria. There were 15 men and 2 women with an average age of 51 years (range 36-69) and an average follow-up of 9.4 years (range 5.0-15.8). The median ASES score improved from 62 (range: 22-88) preoperatively to 90 (range: 50-100) postoperatively (P = .011). Median satisfaction was 8 out of 10 (range: 2-10). There was no correlation between patient age or defect size and PROs. Postoperatively, patients reported significant improvements in recreational and sporting activity as well as the ability to sleep on the affected shoulder (P ≤ .05). Three patients failed and required revision surgery. The Kaplan-Meier analysis determined an overall survivorship rate of 80% at 5 years. CONCLUSION: The presented study illustrates significant improvements for PROs, improved ability to perform recreational and sporting activities, and a survival rate of 80% at a mean of 9.4 years after microfracture for focal chondral humeral head defects.

Improved restoration of biomechanical factors using a narrow-box shaped reconstruction compared to a wide one in superior capsular reconstruction for irreparable supraspinatus tendon tears: a biomechanical study using a static shoulder simulator.

HYPOTHESIS AND/OR BACKGROUND: Extensive, irreparable rotator cuff tears remain a surgical challenge and multiple treatment options are proposed and currently in use. To biomechanically compare superior glenohumeral translation, subacromial contact pressures, and area in a box-shaped reconstruction using the long head of the biceps tendon (LHBT) in an irreparable supraspinatus tendon tear model. METHODS: Seven cadaveric shoulders (mean age 61 years; range 32-84 years; standard deviation 22.3) were tested with a custom testing rig used to evaluate superior translation; subacromial contact pressures; and areas at 0°, 30°, and 60° of glenohumeral abduction. Conditions tested included the native state; a complete tear of the supraspinatus tendon; a wide box-shaped, double-bundle LHBT superior capsular reconstruction (BS-SCR); and a narrow BS-SCR. RESULTS: Compared with the wide BS-SCR, the narrow BS-SCR had statistically significantly lower median contact pressure at 30° and 60°. The subacromial contact area showed a statistically significant difference at 0° (P = .001) and 30° (P = .004) for the narrow BS-SCR compared with the wide BS-SCR. At an abduction angle of 0°, the narrow BS-SCR could restore superior translation significantly better compared with the wide construct. For all angles, the wide and narrow BS-SCR increased the median subacromial distance statistically significantly. The contact areas in 30° and 60° of abduction were higher for all scenarios, both peaking in the intact state in 30° with approximately 600 mm2. CONCLUSIONS: In comparison to a wide BS-SCR, a narrow BS-SCR using the LHBT has biomechanical advantages in regard to subacromial contact pressures, the subacromial contact areas, as well as the acromiohumeral distance. The width of the reconstruction, therefore, has a direct influence on the success of the technique.

Risk factors for intracellular fatty accumulation in rotator cuff muscle: a histologic analysis.

BACKGROUND: Fatty accumulation in rotator cuff muscles has been associated with shoulder dysfunction, risk of repair failure, and poor postoperative outcomes. This study sought to assess risk factors associated with true fatty accumulation based on histologic analysis and determine whether preoperative function directly correlated with this fatty rotator cuff accumulation. METHODS: Supraspinatus muscle biopsy specimens obtained prospectively from patients undergoing arthroscopic rotator cuff repair were stained with LipidTOX to quantify lipid accumulation. Two-step cluster analysis with Goutallier classification was used to define the fatty and non-fatty rotator cuff groups. We further performed a receiver operating characteristic curve analysis to confirm the group cutoff values. RESULTS: In total, 51 patients (aged 60.1 ± 10.5 years) were included. There were 19 high-grade partial tears, 10 small tears, 7 medium tears, 10 large tears, and 5 massive tears. Both cluster and receiver operating characteristic curve analyses yielded a cutoff value of 30% LipidTOX/4',6-diamidino-2-phenylindole (DAPI) separating the fatty vs. non-fatty groups. In the univariate analysis, patients with fatty rotator cuffs were aged 63.2 years on average compared with 59.7 years in the non-fatty group (P = .038). Female patients made up 57.1% of the fatty cohort, which was statistically higher than the non-fatty group (P = .042). Massive and large tears were more likely to occur in the fatty group (P = .005). In the multivariate analysis, full tendon tears had the largest predictive status of falling into the fatty group (odds ratio, 15.4; P = .008), followed by female sex (odds ratio, 4.9; P = .036). Patients in the fatty group had significantly higher American Shoulder and Elbow Surgeons scores (P = .048) and lower visual analog scale scores (P = .002). DISCUSSION AND CONCLUSION: This prospective histologic assessment revealed that full-thickness rotator cuff tears and female sex were the largest risk factors for intracellular lipid accumulation. Although tear size correlated with fatty accumulation, the sex disparity is a noteworthy finding that warrants further research.

Augmented reality-assisted intraoperative navigation increases precision of glenoid inclination in reverse shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is the standard of care for patients with glenohumeral osteoarthritis and rotator cuff deficiency. Preoperative RTSA planning based on medical images and patient-specific instruments has been established over the last decade. This study aims to determine the effects of using augmented reality-assisted intraoperative navigation (ARIN) for baseplate positioning in RTSA compared to preoperative planning. It is hypothesized that ARIN will decrease deviation between preoperative planning and postoperative baseplate positioning. Moreover, ARIN will decrease deviation between the (senior) more (>50 RTSAs/yr) and less experienced (junior) surgeon (5-10 RTSAs/yr). METHODS: Preoperative CT scans of 16 fresh-frozen cadaveric shoulders were obtained. Baseplate placements were planned using a validated software. The data were then converted and uploaded to the augmented reality system (NextAR; Medacta International). Each of the 8 RTSAs were implanted by a senior and a junior surgeon, with 4 RTSAs using ARIN and 4 without. A postoperative CT scan was performed in all cases. The scanned scapulae were segmented, and the preoperative scan was laid over the postoperative scapula by the nearest iterative point cloud analysis. The deviation from the planned entry point and trajectory was calculated regarding the inclination, retroversion, medialization (reaming depth) and lateralization, anteroposterior position, and superoinferior position of the baseplate. Data are reported as mean ± standard deviation (SD) or mean and 95% confidence interval (CI). P values < .05 were considered statistically significant. RESULTS: The use of ARIN yielded a reduction in the absolute difference between planned and obtained inclination from 9° (SD: 4°) to 3° (SD: 2°) (P = .011). Mean difference in planned-obtained inclination between surgeons was 3° in free-hand surgeries (95% CI: -4 to 10; P = .578), whereas this difference reduced to 1° (95% CI: -6 to 7, P = .996) using ARIN. Retroversion, medialization (reaming depth) and lateralization, anteroposterior position, and superoinferior position of the baseplate were not affected by using ARIN. Surgical duration was increased using ARIN for both the senior (10 minutes) and junior (18 minutes) surgeon. CONCLUSIONS: The implementation of ARIN leads to greater accuracy of glenoid component placement, specifically with respect to inclination. Further studies have to verify if this increased accuracy is clinically important. Furthermore, ARIN allows less experienced surgeons to achieve a similar level of accuracy in component placement comparable to more experienced surgeons. However, the potential advantages of ARIN in RTSA are counterbalanced by an increase in operative time.

Yoke procedure as a salvage treatment option for failed reverse total shoulder arthroplasty with irreconstructible glenoid.

BACKGROUND: Glenoid bone loss is a known challenge in primary and revision reverse total shoulder arthroplasty. In severe deficiency, even placing the baseplate in alternative centerline or using an augmented baseplate may be insufficient. This study reports on the use of a soft tissue resurfacing technique using Achilles tendon allograft, coined Yoke procedure, for salvage treatment of glenoid deficient shoulder requiring reconstruction. MATERIALS AND METHODS: All patients who underwent the Yoke procedure between 2014 and 2020 by a single surgeon at a single academic center were identified and had their charts retrospectively reviewed. Demographics and surgical information were recorded. Preoperative X-rays and 3D-computed tomography scans were reviewed to classify patient glenoid types, evaluate glenoid medialization, and measure shoulder angles. Preoperative and postoperative range of motions and patient-reported outcome scores were evaluated, including anterior elevation, external rotation, internal rotation, visual analog scale, subjective shoulder value score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons (ASES) scores. Postoperative radiographs and follow-up notes were reviewed to evaluate postoperative complication profiles at 1 year. RESULTS: Seven patients with a median age of 69 years (range, 54-77 years) underwent Yoke procedure and had a median 12-month follow-up (range, 9-56 months). All patients were female and had a median of 2 prior shoulder surgeries (range, 0-13). Of all the patients, the most common comorbidity was osteoporosis (6) followed by rheumatoid arthritis (3). Of the 5 patients who had previous arthroplasty, the most common indications were baseplate failure (4), followed by instability (3) and infection (3). The median visual analog scale score improved from 8 (range, 3-9) to 2 (range, 1-4). The median Simple Shoulder Test improved from 8% (range, 0%-42%) to 33% (range, 17%-83%). The median ASES score improved from 15 (range, 5-38) to 52 (range, 40-78). The median anterior elevation and external rotation improved from 20° (range, 0°-75°) to 100° (range, 40°-145°) and 10° (range, 0°-20°) to 20° (range, 0°-55°), respectively. There was no change in median internal rotation. As of the last follow-up, one patient reported postoperative complications of anterior-superior implant escape, heterotopic ossification, and scapular notching. CONCLUSION: The Yoke procedure is a promising salvage treatment that can offer patients consistent pain reduction and moderate functional improvements at short-term follow-up. In the setting of poor bone quality and severe glenoid deficiency, glenoid baseplate implantation may not be absolutely necessary for a pain-relieving, functionally acceptable outcome.

How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery.

BACKGROUND: Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain. METHODS: In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n = 20), 15 pills (n = 29), or 23 pills (n = 25). The primary outcome was maximum possible opioid consumption within 2 weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2 weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2 weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P = .047). RESULTS: Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P < .001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P = .20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P = .43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P = .20). CONCLUSION: After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.

Postoperative cognitive dysfunction after beach chair positioning compared to supine position in orthopaedic surgery in the elderly.

INTRODUCTION: Postoperative cognitive dysfunction (POCD) occurs in up to 26% of patients older than 60 years 1 week after non-cardiac surgery. Intraoperative beach chair positioning (BCP) is advantageous for some types of shoulder surgery. However, this kind of positioning leads to a downward bound redistribution of blood volume, with possible hypoperfusion of the brain. We hypothesized that patients > 60 years undergoing orthopaedic shoulder surgery in a BCP might experience more POCD than patients operated in the supine position (SP). MATERIAL AND METHODS: A single-centre, prospective observational trial of 114 orthopaedic patients was performed. Study groups were established according to the type of intraoperative positioning. Anaesthesiological management was carried out similarly in both groups, including types of anaesthetics and blood pressure levels. POCD was evaluated using the Trail Making Test, the Letter-Number Span and the Regensburger Word Fluency Test. The frequency of POCD 1 week after surgery was considered primary outcome. RESULTS: Baseline characteristics, including duration of surgery, were comparable in both groups. POCD after 1 week occurred in 10.5% of SP patients and in 21.1% of BCP patients (p = 0.123; hazard ratio 2.0 (CI 95% 0.794-5.038)). After 4 weeks, the incidence of POCD decreased (SP: 8.8% vs. BCP: 5.3%; p = 0.463). 12/18 patients with POCD showed changes in their Word Fluency Tests. Near-infrared spectroscopy (NIRS) values were not lower in patients with POCD compared to those without POCD (54% (50/61) vs. 57% (51/61); p = 0.671). CONCLUSION: POCD at 1 week after surgery tended to occur more often in patients operated in beach chair position compared to patients in supine position without being statistically significant.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review.

INTRODUCTION: The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures. METHODS: We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects. RESULTS: Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID. CONCLUSION: In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.

Long head of biceps tendon autograft is effective in the management of large to massive rotator cuff tear: a systematic review.

PURPOSE: The aim of this systematic review is to review the functional, clinical and radiological outcomes of patients undergoing large to massive rotator cuff repair with long head of biceps tendon (LHBT) autograft, as well as compare these to standard arthroscopic cuff repair. METHODS: A review of the online Medline database was conducted on 20 October 2022 according to PRISMA guidelines and registered prospectively on the PROSPERO database. Clinical studies assessing patients with large to massive rotator cuff tears undergoing LHBT autograft repair were included. All studies reported on functional outcomes, range of movement (ROM) and radiological re-tear rates. The Methodological Index for Non-Randomised Studies (MINORS) tool was used to appraise all studies. RESULTS: The search strategy identified ten studies for inclusion including a total of 594 patients. Five studies were comparable (346 patients), assessing LHBT autograft repair against arthroscopic rotator cuff repair without autograft. A variety of techniques of LHBT autograft were used across all studies, including bridging and augmentation styles. Radiographic comparison showed lower re-tear rates in the LHBT autograft group with two studies demonstrating statistically significant results. Pain scores, functional outcomes and ROM were significantly improved post-operatively in all studies for LHBT autograft patients, with no significant difference when compared to standard arthroscopic repair. CONCLUSION: LHBT autograft looks to significantly improve functional scoring and range of motion in patients with large to massive rotator cuff tears. When compared to standard arthroscopic cuff repair, LHBT autograft appears to significantly reduce the re-tear rate. Further randomised studies are needed to assess the efficacy of this technique.

Single injection combined suprascapular and axillary nerve block: A randomised controlled non-inferiority trial in healthy volunteers.

BACKGROUND: A shoulder block without lung affection is desirable. In this study, we compared a low versus a high volume of a modified supraclavicular brachial plexus block. We hypothesised that a low volume of local anaesthetic would provide non-inferior block success rate with better preserved lung function. METHODS: Healthy volunteers were randomised to receive ultrasound guided 5 or 20 ml ropivacaine 0.5% at the departure of the suprascapular nerve from the brachial plexus. Primary outcome was successful shoulder block-defined as cutaneous sensory affection of the axillary nerve and motor affection of the suprascapular nerve (>50% reduction in external rotation force measured with dynamometry). We used a non-inferiority margin of 20%. Secondary outcome was change in lung function measured with spirometry. RESULTS: Thirteen of 16 (81.3%; 95% confidence interval [CI] 57.0% to 93.4%) in the 5 ml group and 15 of 16 (93.8%; 95% CI 71.7% to 98.9%) in the 20 ml group had successful shoulder block (p = .6). The ratio of the event rates of the 20 ml (standard) and 5 ml (intervention) groups was (15/16)/(13/16) = 0.937/0.813 = 1.15 (95% CI 0.88 to 1.51). All mean reductions in lung function parameters were non-significantly lower in the 5 ml group compared with the 20 ml group. CONCLUSION: For our primary outcome, the 95% CI of the difference of event ratio included the non-inferiority margin. We are therefore unable to conclude that 5 ml LA is non-inferior to 20 ml LA with respect to block success rate.

Reducing rebound pain severity after arthroscopic shoulder surgery under general anesthesia and interscalene block: a two-centre randomized controlled trial of pre-emptive opioid treatment compared with placebo.

PURPOSE: Although a single-injection interscalene block provides effective early postoperative analgesia following shoulder surgery, patients may experience "rebound pain" when the block resolves. Our objective was to determine if oral hydromorphone (2 mg) given six hours after a single-injection interscalene block for arthroscopic shoulder surgery leads to a clinically significant reduction in the severity of rebound pain. METHODS: After approval from research ethics boards, we conducted a two-centre, parallel-group, double-blind, randomized, placebo-controlled superiority trial. Patients received preoperative interscalene block, general anesthesia, and either hydromorphone or placebo six hours after the block. The primary outcome was the worst pain score in the first 24 hr postoperatively, measured on an 11-point (0-10) numerical rating scale. RESULTS: A total of 73 participants were randomly assigned to either the hydromorphone or placebo group. There was no statistically significant difference in the mean (standard deviation) worst pain score within 24 hr between the hydromorphone and placebo groups (6.5 [2.4] vs 5.9 [2.3]; mean difference, 0.6; 95% confidence interval, -0.5 to 1.8). Similarly, we did not find any significant difference in the pain trajectory, opioid use, or incidence of nausea and vomiting between the groups. The mean time to worst pain was 14.6 hr, and the mean time to first rescue analgesia was 11.3 hr after interscalene block. CONCLUSION: Hydromorphone 2 mg given six hours after interscalene block did not reduce the severity of rebound pain postoperatively compared with placebo in patients undergoing arthroscopic shoulder surgery. STUDY REGISTRATION: ClinicalTrials.gov (NCT02939209); registered 19 October 2016.

RéSUMé: OBJECTIF: Bien qu'un bloc interscalénique à injection unique fournisse une analgésie postopératoire précoce efficace après une chirurgie de l'épaule, les patient·es peuvent ressentir une « douleur de rebond ¼ lorsque le bloc se résorbe. Notre objectif était de déterminer si l'hydromorphone orale (2 mg) administrée six heures après une injection unique de bloc interscalénique pour une chirurgie arthroscopique de l'épaule entraînait une réduction cliniquement significative de la gravité de la douleur de rebond. MéTHODE: Après l'approbation des comités d'éthique de la recherche, nous avons mené une étude de supériorité dans deux centres, en groupes parallèles, à double insu, randomisée et contrôlée par placebo. Les patient·es ont reçu un bloc interscalénique préopératoire, une anesthésie générale et de l'hydromorphone ou un placebo six heures après le bloc. Le critère d'évaluation principal était le pire score de douleur au cours des premières 24 heures postopératoires, mesuré sur une échelle d'évaluation numérique de 11 points (0 à 10). RéSULTATS: Au total, 73 personnes ont participé à l'étude et ont été aléatoirement assignées au groupe hydromorphone ou au groupe placebo. Il n'y avait pas de différence statistiquement significative dans le score moyen (écart type) de la pire douleur dans les 24 heures entre les groupes hydromorphone et placebo (6,5 [2,4] vs 5,9 [2,3]; différence moyenne, 0,6; intervalle de confiance à 95 %, −0,5 à 1,8). De même, nous n'avons trouvé aucune différence significative dans la trajectoire de la douleur, la consommation d'opioïdes ou l'incidence de nausées et vomissements entre les groupes. Le temps moyen jusqu'à la pire douleur était de 14,6 heures, et le temps moyen jusqu'à la première analgésie de secours était de 11,3 heures après le bloc interscalénique. CONCLUSION: L'hydromorphone 2 mg administrée six heures après le bloc interscalénique n'a pas réduit la gravité de la douleur de rebond postopératoire par rapport au placebo chez les patient·es bénéficiant d'une chirurgie arthroscopique de l'épaule. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02939209); enregistrée le 19 octobre 2016.