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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., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Recovery after anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) has many similarities; however, recently surgeons have suggested patients undergoing rTSA have a less difficult postoperative course with less pain compared with aTSA patients. Given the heightened awareness to postoperative pain control and opioid consumption, as well as the expanding indications for rTSA, we sought to determine the differences in pain and opioid consumption between aTSA and rTSA patients in a 12-week postoperative period., Methods: A retrospective chart review was performed to identify all patients who underwent a primary aTSA or rTSA from January 2013 to April 2018 at a single institution. Patients with recorded visual analog scale (VAS) and American Shoulder and Elbow Surgeons scores were included for analysis. Revision arthroplasties were excluded. VAS scores were recorded preoperatively and at standard 2-week, 6-week, and 12-week postoperative time points. P values < .05 were considered statistically significant, except where Bonferroni corrections were applied., Results: A total of 690 patients underwent TSA (278 aTSA, 412 rTSA). Preoperatively, aTSA and rTSA patient groups had similar VAS scores (6 vs. 6, P = .38). Postoperatively, the aTSA group had a higher VAS at the 6-week visit, compared with rTSA patients (2.8 vs. 2.2, P = .003). aTSA patients remained on opioids at a higher rate at the 2-week (62.4% vs. 45.6%, P ≤ .001) time period. aTSA patients needed more opioid prescription refills before the 2-week (61.7% vs. 45.5%, P ≤ .001) and 6-week (40.4% vs. 30.7%, P = .01) follow-up visits., Conclusions: Despite similar preoperative VAS and rates of preoperative opioid use, aTSA patients required more opioid medication refills and remained on opioids for a longer duration in the early postoperative period to achieve similar postoperative pain control as indicated by similar VAS. This study suggests that the recovery from rTSA is less difficult compared with aTSA as indicated by VAS and opioid consumption., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution., Methods: A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations., Results: A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes., Conclusions: There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Preoperative teres minor insufficiency has been identified as a risk factor for poor restoration of external rotation (ER) after reverse total shoulder arthroplasty (RTSA). However, there has been little investigation regarding muscle activation patterns generating ER. This prospective study sought to determine the timing and activation levels of the shoulder girdle musculature during ER in well-functioning RTSAs with an intact teres minor using a lateralized design., Methods: Patients who underwent RTSA ≥1 year previously with functional ER, an American Shoulder and Elbow Surgeons (ASES) score >70, superior rotator cuff deficiency, and an intact teres minor were identified. Electrophysiological and kinematic analyses were performed during ER in the modified neutral position (arm at side with 90° of elbow flexion) and in abduction (AB) (shoulder abducted 90° with 90° of elbow flexion). Dynamometer-recorded torque and position were pattern matched to electromyography during ER. The root-mean-square and integrated electromyography (in microvolts × milliseconds with standard deviation [SD]), as well as median frequency (MF) (in hertz with SD), were calculated to determine muscle recruitment. Pair-wise t test analysis compared muscle activation (P < .05 indicated significance)., Results: After an a priori power analysis, 16 patients were recruited. The average ASES score, visual analog scale pain score, and ASES subscore for ER in AB ("comb hair") were 87.7, 0.5, and 2.75 of 3, respectively. In AB, muscle activation began with the upper trapezius, middle trapezius, and latissimus dorsi, followed by the anterior deltoid activating to neutral. With ER beyond neutral, the teres major (9.6 μV × ms; SD, 9.2 μV × ms) initiated ER, followed by the teres minor (14.1 μV × ms; SD, 18.2 μV × ms) and posterior deltoid (11.1 μV × ms; SD, 9.3 μV × ms). MF analysis indicated equal contributions of the teres major (1.1 Hz; SD, 0.5 Hz), teres minor (1.2 Hz; SD, 0.4 Hz), and posterior deltoid (1.1 Hz; SD, 0.4 Hz) in ER beyond neutral. In the modified neutral position, the upper trapezius and middle trapezius were not recruited to the same level as in AB. For ER beyond neutral, the teres major (9.5 μV × ms [SD, 9 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), teres minor (11.4 μV × ms [SD, 15.1 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), and posterior deltoid (8.5 μV × ms [SD, 8 μV × ms]; MF, 1.2 Hz [SD, 0.3 Hz]) were activated in similar sequence and intensity as AB. No differences in muscle activation duration or intensity were noted among the teres major, teres minor, and posterior deltoid (P > .05)., Conclusion: Active ER after RTSA is complex and is not governed by a single muscle-tendon unit. This study establishes a sequence, duration, and intensity of muscle activation for ER in well-functioning RTSAs. In both tested positions, the teres major, teres minor, and posterior deltoid function equally and sequentially to power ER., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions., Methods: In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection., Results: MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone., Methods: Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone., Results: Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001)., Conclusion: Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The opioid epidemic has become a central focus in health care. In an effort to reduce opioid use, orthopedic surgeons use multimodal strategies to control postoperative pain. However, no clear consensus exists on ideal pain management strategies after shoulder arthroplasty, and most protocols are opioid-driven. This study sought to determine if patients undergoing shoulder arthroplasty using a postoperative opioid-sparing pain-control regimen would have equivalent pain scores and satisfaction as patients using a traditional opioid-based regimen., Methods: Patients undergoing primary anatomic or reverse total shoulder arthroplasty were prospectively enrolled and randomized into an opioid-sparing (OS) or a traditional opioid-based (OB) postoperative pain protocol. Both groups received opioid education, periarticular injection with liposomal bupivacaine, and preoperative and postoperative multimodal management (acetaminophen, celecoxib, and gabapentin). The OB group was discharged with 40 oxycodone tablets and standard icing, whereas the OS group received ketorolac during admission, continuous cryotherapy, and discharged with 10 oxycodone tablets for rescue. Patients were queried regarding levels of pain and opioid consumption at days 1-7 and at 2, 6, and 12 weeks postoperatively. Patient satisfaction was recorded at 1, 2, 6, and 12 weeks. Range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) scores were assessed preoperatively and at 12 weeks postoperatively. Complications, readmissions, and reoperations were recorded., Results: In 78 patients, no difference in VAS pain scores were seen at any time between groups. The OS group consumed less oral morphine equivalents (OME) from inpatient hospitalization to 12 weeks postoperatively (P < .05). Total OME consumption was reduced by 213% for the OS vs. the OB group (112 vs. 239; P < .0001). The OS group consumed fewer opioid pills at all time points (P < .05). A 395% reduction in number of opioid pills consumed in the first 12 weeks postoperatively was seen in the OS vs. the OB group (4.3 vs. 17.0; P < .0001). Significantly more patients in the OS group discontinued opioids by 2 weeks postoperatively (86.1% vs. 58.5%; P = .011), and 94.4% in the OS group discontinued opioids by 6 weeks postoperatively. The OS group was more satisfied with pain management at 1 and 6 weeks (P = .05). No difference in ROM, ASES or SANE scores, complications, readmissions, or reoperations were seen between groups., Conclusions: This study demonstrated a nearly 4-fold reduction in opioid pain pill consumption and earlier cessation of opioids with an OS pain management protocol. Patients also reported higher satisfaction with this pain management strategy., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair., Methods: Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant., Results: Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745., Conclusion: Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Current ulnar collateral ligament (UCL) reconstruction techniques are substantially less stiff and demonstrate lower load to failure compared with the native UCL. UCL repair with the addition of an internal brace has demonstrated superior biomechanical performance compared with docking UCL reconstruction, but internal bracing has not yet been used in UCL reconstruction., Hypothesis/purpose: To evaluate the time-zero biomechanical performance of a UCL docking technique reconstruction with and without an internal brace compared with native UCL properties., Methods: Twelve matched pairs of cadaveric elbows were dissected and fixed at 90° for biomechanical testing. A cyclic valgus torque protocol was used to test the anterior band of the UCL in native specimens. After native specimens were failed, palmaris grafts were used for a docking reconstruction with or without internal brace and were subjected to the same valgus torque test protocol. Torsional stiffness, ultimate failure torque, and ulnohumeral gapping were determined., Results: Stiffness in UCL reconstructions using a standard docking technique (3.0 ± 0.4 N m/deg) were significantly less stiff (P < .001) than native UCL (4.0 ± 0.8 N m/deg), whereas reconstructions using an internal brace (3.6 ± 0.6 N m/deg) were not different (P = .120) compared with native. Ultimate failure torque for standard docking (18.3 ± 4.1 N m) was significantly lower (P < .001) than native UCL (36.9 ± 10.1 N m), whereas the internal brace samples (35.3 ± 9.8 N m) were not different (P = .772) than native., Conclusion: UCL reconstruction with an internal brace augmentation provides superior stiffness and time-zero failure strength when compared with the standard docking technique., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)