Search

Anxiety and depression are the two most commonly diagnosed psychiatric disorders in the US. The effect of these disorders on total shoulder arthroplasty (TSA) outcomes must be appreciated. The purpose of this study was to examine the correlation between preoperative diagnosis of anxiety and depression and its association with postoperative outcomes after TSA. The secondary goals were to determine whether patients contemporaneously being treated with medicine for their mental health diagnosis fared better than a non-medicated cohort and to examine the degree to which PROMIS Mental Health (PROMIS-MH) scores correlate with patient outcomes. Our hypothesis is that a history of anxiety and/or depression will negatively impact patient outcomes after TSA.A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic and reverse TSA patients (aTSA, rTSA) with either anxiety and/or depression (aTSApsych+, rTSApsych+) were identified and compared to a cohort of patients without a mental health diagnosis enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion (ROM), adverse events (AE) and clinical outcome metric scores:PROMIS-MH, American Shoulder and Elbow Surgeons (ASES), Constant, Shoulder Arthroplasty Smart Score (SAS) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by MCID and SCB thresholds where applicable.218 patients (114 rTSA and 95 aTSA) had a diagnosis of either anxiety and/or depression and 378 (153 rTSA and 217 aTSA) had no history. Although both cohorts achieved MCID and SCB for postoperative ASES, the psych+ cohort resulted in lower postoperative outcomes scores (p0.05), higher AE, and significantly lower Δ differences in all variables when compared to the psych negative cohort. There were no differences in outcome scores after rTSApsych+ or aTSApsych+ between patients being treated for anxiety/depression compared to not receiving treatment. PROMIS-MH score was positively correlated with postoperative outcomes and patient satisfaction.The current study demonstrates that patients with anxiety and/or depression who undergo TSA have inferior postoperative outcomes and higher rates of AE compared to a cohort without a mental health diagnosis. Additionally, patients on medications for treatment of depression and/or anxiety did not gain any significant benefit in terms of their postoperative shoulder outcomes or satisfaction rate compared to those with a diagnosis but not on medication. Additionally, we found that, independent of a patient's underlying shoulder pathology or psychiatric diagnosis, lower PROMIS-MH scores was correlated with worse postoperative outcomes.

Since the introduction of the Grammont-style reverse total shoulder arthroplasty, the humeral stem design has been modified with improved clinical outcomes. Two distinct humeral designs have been used extensively: the inlay design, in which the humeral tray is seated within the metaphysis, and the onlay design, in which the humeral tray sits on the metaphysis at the level of the humeral neck cut. The purpose of this systematic review was to determine whether there are differences in clinical outcomes and complication rates between these designs.The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to perform this systematic review. A search of MEDLINE, PubMed, and Embase was performed to identify all studies comparing the clinical results of both humeral designs. Primary outcomes included patient-reported outcome measures, shoulder range of motion, and incidence of complications.From the 156 identified publications, 12 studies were included in the final review. A total of 1447 patients were included, with a minimum follow-up period of 12 months. At final follow-up, both implants demonstrated significant improvements in comparison to preoperative baseline. On comparison of the inlay vs. onlay groups, the American Shoulder and Elbow Surgeons score was higher in the inlay group (mean difference, 2.53 [95% confidence interval, 0.27-4.78]; P = .03). Postoperative motion, even if statistically greater in the onlay group (differences of 5° in forward flexion [P .001], 3° in abduction [P = .003], and 4° in external rotation [P .001]), was not clinically different. On comparison of complications, the inlay group showed more instances of scapular notching (93 of 322 patients vs. 70 of 415 patients; odds ratio, 0.35; P .001) but fewer scapular spine fractures (26 of 727 patients vs. 21 of 559 patients, P = .09).Inlay and onlay humeral tray designs in reverse total shoulder arthroplasty demonstrate similar clinical improvements postoperatively. Onlay implants have a low rate of scapular notching but a higher rate of scapular spine fracture. Understanding the strengths and weaknesses of the 2 humeral tray designs is important to provide surgeons with options to tailor surgical plans for high-risk patients.

The purpose of our study was to examine the impact that an increased body mass index (BMI) has on arthroscopic rotator cuff repair (aRCR) outcomes.We identified a sample of 313 patients who underwent aRCR at our institution from 2017 to 2020. Patients were classified into cohorts by BMI: normal BMI (25), overweight (25-30), and obese (≥30). Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Pain Interference, Pain Intensity, and Upper Extremity) and Clinical Global Impressions scale rating of pain and functional improvement after surgery were obtained at 1 year postoperatively. The significance of the BMI category as a predictor for outcomes was evaluated using multiple linear and multivariable logistic regressions. Receiver operating characteristic curve analysis with Youden's J-statistic was used to determine optimal BMI cutoff for predicting likelihood of achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) on the Clinical Global Impressions scales.Obesity was a significant predictor of reduced preoperative-to-postoperative improvement in the PROMIS Upper Extremity score (Obesity was not found to be an independent risk factor for increased rotator cuff tear size or tendon involvement but was nonetheless associated with worse upper extremity function and pain after aRCR.

Patient's willingness and barriers for discharge after shoulder arthroplasty (SA) has not been studied. The aim of this study was to prospectively analyze patient's willingness for discharge and barriers to discharge beyond postoperative day #1 (POD#1) after SA.In this prospective study, patients undergoing primary or revision SA (anatomic, reverse, or hemiarthroplasty) at our institution were enrolled to determine their willingness and concerns for discharge after SA. Patient's willingness for discharge was inquired daily until discharge. Demographic information, patient's medical history, intraoperative details (duration of surgery, estimated blood loss, intraoperative complication), discharge disposition, length of stay (LOS), and reasons for extension of LOS beyond POD#1 were analyzed.A total of 184 patients who underwent SA were included. Eight patients were discharged on POD#0, 114 patients on POD#1, 37 patients on POD#2, and 25 patients after POD#2. One hundred nineteen (119) patients were discharged to home, 40 were discharged to home with services, 15 were discharged to nursing facilities, and 10 were discharged to rehabilitation centers. Reasons for extension of LOS past POD#1 included patients failing to clear home safety evaluation (n = 4), inadequate pain control (n = 6), worsening of preexisting medical conditions (n = 8), delay in patient disposition (awaiting placement in a rehabilitation facility [n = 6] and awaiting culture results [n = 9]). Social reasons (n = 29) were the most common reasons for extension of LOS. These included patients requesting an extra day of stay (n = 20), patients requesting rehabilitation facility placement (n = 5), lack of a timely ride home (n = 2), and family-related reasons (death in the family [n = 1], lack of home help [n = 1]).This prospective study demonstrates modifiable factors associated with LOS beyond POD#1 (inadequate pain control, logistic delays in disposition, and patient-related social concerns) after SA. With increasing interest in same-day discharge and rising concerns to control cost and use bundled payment initiatives with SA, improving patient's willingness to discharge by addressing their concerns can improve early discharge after SA.

Tophaceous gout affecting the olecranon region can result in local discomfort, skin ulceration, secondary infection, and considerable disability if left untreated. However, there are limited reports of outcomes, including postoperative complications and recurrence after surgical excision of tophaceous gout deposits at the elbow. The aim of this study is to present our surgical technique and minimum one-year outcomes after surgical excision of tophaceous gout involving the elbow.A retrospective chart review was performed on all patients from a single surgeon's practice who underwent surgical excision of gouty tophi of the elbow between January 2016 and December 2019. The indications for surgical excision of tophi included failure of medical management, presence of skin ulceration, and/or large gouty tophi. The relevant data pertaining to patient demographics, preoperative findings, intraoperative findings, surgical pathology reports, and short-term postoperative complications were collected through retrospective chart review. Patients were subsequently contacted for a follow-up telehealth visit to assess recurrence of gouty tophi, functional outcomes, and range of motion (ROM) measurements.Six male patients underwent 7 total procedures (1 bilateral elbow) during the study period. The mean age of the cohort at the time of surgery was 56.0 ± 7.1 years (range: 45.3-63.5). The mean size of the swelling in 2 maximum dimensions was 5.8 × 3.4 cm. There were no intraoperative or immediate postoperative wound complications. There was no recurrence of gouty tophi at a mean follow-up time of 30.8 months (range: 14.0-43.5). Patients reported physiologic ROM (mean flexion-extension arc of 2°-134°) with no pain at final follow-up.Surgical treatment of tophaceous gout of the elbow is associated with a low risk of wound complication and recurrence.

History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR.All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared.From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts.RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.

Background The objective of this study was to assess patient satisfaction and preference for telemedicine vs. in-person visits for outpatient shoulder and elbow musculoskeletal consultation during the coronavirus disease 2019 (COVID-19) pandemic and in the future. Methods Patients who had telemedicine visits for shoulder and elbow musculoskeletal complaints at a single institution from March through June 2020 were invited to respond to a post-visit survey. The survey included a standardized questionnaire that focused on the patient’s satisfaction with the telemedicine visits during the pandemic and preference for using the telemedicine platform in the future, following the pandemic. Additional details regarding their virtual visits (severity of medical condition, as well as previous virtual or emergency department visits) were also obtained. Data regarding patient demographic characteristics and visit details (primary diagnosis, type of visit, length of visit, and treating physician) were extracted from the electronic medical records. Results In total, 153 patients participated in the study. Overall, high satisfaction scores regarding the telemedicine visits were noted: 91% of patients reported that their concerns were adequately addressed, 89% would recommend telemedicine to a friend, and 94% stated that they would use the telemedicine platform again in the presence of a situation similar to the COVID-19 pandemic. However, the majority of patients (76%) reported a preference for in-person visits for the same musculoskeletal complaint if it were not for COVID-19. A telemedicine visit duration > 10 minutes and a first-time telemedicine visit correlated with higher satisfaction rates (P = .037 and P = .001, respectively). Conclusions COVID-19 has provided a boost to the use of our telemedicine platform, with a high satisfaction rate among patients with shoulder and elbow musculoskeletal complaints, largely owing to safety reasons and limited access to in-person doctor visits. However, a considerable number of patients would have preferred in-person visits for similar health complaints if there were no pandemic. Further research on optimizing the selection of patients for telemedicine visits and addressing their expectations and concerns regarding their visits will improve patients’ preference for future telemedicine visits.

Purpose: The purpose of this study is to evaluate the patient-reported outcomes of open Latarjet (OL) compared to arthroscopic Latarjet (AL) for anterior shoulder instability. Methods: A retrospective review of patients who underwent either OL or AL for anterior shoulder instability between 2011 and 2019 was performed. Recurrent instability, visual analog scale (VAS) score, Shoulder Instability-Return to Sport after Injury (SIRSI), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability (WOSI) score, patient satisfaction, willingness to undergo surgery again, and return to work/sport (RTW/RTS) were evaluated. A P value of < .05 was considered to be statistically significant. Results: Our study included 102 patients in total; 72 patients treated with OL, and 30 treated with AL. There were no demographic differences between the two groups (P > .05 for all). At final follow up (mean of 51.3 months), there was no difference between those that underwent OL or AL in the reported WOSI, VAS, VAS during sports, SSV, and SIRSI scores, nor in patient satisfaction, or whether they would undergo surgery again (P > .05). Overall, there was no significant difference in the total rate of RTP (65% vs 60.9%; P = .74), or timing of RTP (8.1 months vs 7 months; P = .35). Additionally, there was no significant difference in the total rate of RTW (93.5% vs 95.5%; P = .75). Overall, 3 patients in the OL group and 2 patients in the AL group had recurrent instability events (6.9% vs 6.7%; P = .96), with no significant difference in the rate of recurrent dislocation (4.2% vs 3.3%; P = .84). Conclusion: In patients with anterior shoulder instability, both the OL and AL are reliable treatment options, with a low rate of recurrent instability, and similar patient-reported outcomes.

Background The Patient-Reported Outcomes Measurement Information System minimal clinically important difference (PROMIS MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of patient-reported outcome measures provide clinical significance to patient-reported outcome measures scores. The goal of this study is to measure the MCID, SCB, and PASS of PROMIS Upper Extremity v2.0 (PROMIS UE) in patients undergoing total shoulder arthroplasty (TSA). Methods All patients who underwent TSA since October 2017 were identified from our institutional database. Patients who had completed the PROMIS UE outcome measure before surgery were asked to complete a PROMIS UE and anchor survey that contained two transition questions to assess patient satisfaction and change in symptoms since treatment. The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS UE score that represented the optimal cutoff for a receiver operating characteristic curve. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by 2 different constants: 1 and 2.77. Results This study enrolled 165 patients. The anchor-based MCID for PROMIS UE was calculated to be 8.05 with an AUC of 0.814. The anchor-based SCB was calculated to be 10.0 with an AUC of 0.727. The distribution-based MCID was calculated to be between 3.12 and 8.65. The PASS was calculated to be 37.2 with an AUC of 0.90. Conclusions The establishment of MCID, SCB, and PASS for PROMIS UE scores after shoulder arthroplasty provides meaningful and objective clinical interpretation of the improvements in outcome scores after TSA.

Background The purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty. Methods Preoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns. Results The 3 reviewers agreed that quality of AXRs was significantly inadequate (P Conclusion Axillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids). Level of evidence Level IV

Purpose To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries. Methods Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported. Results The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients. Conclusions CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS. Level of Evidence IV, therapeutic case series.

With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control.The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press Ganey satisfaction surveys.A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press Ganey survey information and no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into 2 groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to morphine milligram equivalents (MME) for direct comparison between different opioid medications.A total of 201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group were 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5 mg), whereas after the initiation of the protocol, they were 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5 mg); P.0001. Average satisfaction with pain control did not change significantly between pre-protocol and post-protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P = .82).A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press Ganey survey.

Purpose To compare biomechanical and clinical outcomes between knotless and knotted anchors in arthroscopic labral repair, specifically in (1) Bankart repair, (2) SLAP repair, (3) posterior labral repair, and (4) remplissage augmentation of Bankart repair. Methods MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to find biomechanical and clinical studies comparing knotted and knotless anchors using the search term “knotless anchor.” Results Overall, 17 studies met inclusion criteria. There were 7 studies evaluating the biomechanical outcomes, of which 5 found mixed results between knotted and knotless anchors for arthroscopic Bankart repair, 1 demonstrated a difference for SLAP repair favoring knotless anchors, and 2 showed no significant difference for Remplissage in terms of ultimate load-to-failure. Four studies evaluated knotless labral anchors compared with knotted anchors in patients undergoing arthroscopic Bankart repair with no significant differences in outcomes reported between the 2 anchor types, except in one study that found an improved visual analog scale score and a lower recurrence and revision rate with knotted anchors. Five studies evaluated knotless anchors compared with knotted anchors in patients undergoing SLAP repair, and none of the included studies found any significant differences in the patient reported outcome measures or revision rates. Of the 5 studies comparing operative time, 4 found a reduced time with knotless anchors. Conclusions The clinical results show no significant differences in outcomes between knotless and knotted anchors for labral repair in the shoulder, including Bankart repair, SLAP repair, and posterior labral repair. However, there was conflicting evidence supporting knotless or knotted anchors in the biomechanical studies. However, operative times may be reduced with the use of knotless anchors. Level of Evidence III, A Systematic Review of Level II and III studies.

To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with pre-existing validated outcome scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC).Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcome scores were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were calculated.The final cohort included 100 patients with AC, of whom there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ± 1.84) compared with the fixed question burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed an excellent correlation with both the ASES (r = 0.80, 95% confidence interval [0.72, 0.86], P.001) and CS (r = 0.76, 95% confidence interval [0.67, 0.83], P .001). Neither ceiling nor floor effects were present.The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in AC. A lower question burden with the PROMIS UE carries potential for wider acceptability with the researchers and patients with shoulder pathology.

Preoperative 3D planning and intraoperative navigation for shoulder arthroplasty has recently gained interest because of the potential to enhance the surgeon's understanding of glenoid anatomy and improve the accuracy of glenoid component positioning. The purpose of our study was to assess the impact of preoperative 3D planning on the surgeon's selection of the glenoid component (standard vs. augmented) and compare duration of surgery with and without intraoperative navigation.We retrospectively analyzed 200 consecutive patients who underwent shoulder arthroplasty. The first group of 100 patients underwent shoulder arthroplasty using standard 2D preoperative planning based on standard radiographs and computed tomographic scans. The second group of 100 patients underwent shoulder arthroplasty using 3D preoperative planning and intraoperative navigation. Type of glenoid component and operative time were recorded in each case.For the group of patients with standard preoperative planning, only 15 augmented glenoid components were used, whereas in the group of patients with 3D preoperative planning and navigation, 54 augments were used (P.001). The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared with those that did not (P.001). This difference diminished as the surgeon became more proficient with the navigation technique.Use of preoperative 3D planning changes the surgeon's understanding of the patient's glenoid anatomy. In our study, using 3D planning increased the likelihood that the surgeon selected an augmented glenoid component compared with 2D planning. Intraoperative navigation slightly lengthened the duration of surgery, but this became insignificant as part of a learning curve within 6 months.

Introduction There is no current standard by which culture specimens from revision shoulder arthroplasty should be handled, processed, cultured, and reported. Due to the relatively low numbers of cases multicenter study may provide information to form consensus recommendations. However, assimilation of multicenter data requires comparable methodologies. The objective of this study was to document and evaluate the extent of variability between surgeons and institutions. Methods An 11-question survey was sent to 20 shoulder surgeons as part of the American Shoulder and Elbow Society (ASES) Periprosthetic Joint Infection (PJI) Multicenter Workgroup. Questions addressed how samples are handled in the operating room by surgeons, processing of tissue samples and explants by laboratories, number of media, culture incubation durations, and culture reporting. Results Common practices regarding specimen handling and processing were identified including prolonged culture incubation times >13 days (94% of participants). However, substantial variation in handling of tissue and explant specimens, number and type of media used, and reporting of results were identified. The majority of surgeons reported using a sterile instrument to harvest each individual tissue specimen (10/17, 59%), more so than using any available instrument (4/17, 24%) or washing and re-using the same instrument (3/17, 18%). Half of the institutions require a time limit by which samples must be processed in the laboratory (8/16, 50%). Nine institutions (9/16, 56%) report cultures in a semi-quantitative manner, while 7 (44%) report cultures in a binary fashion. Five institutions reported having performed a negative control study, and the rate of positive cultures ranged between 0% and 17%. The majority of positive cultures from the negative controls contained Cutibacterium (92%). Discussion Specimen handling, processing, culturing, and reporting varies widely between institutions. Due to the risk of false positives as demonstrated by negative control studies, surgeons should be cognizant of potential sources of contamination at the specimen handling level in the operating room and specimen processing level in the laboratory. Given the challenges in interpretation of positive cultures in revision shoulder arthroplasty, further studies are needed to determine whether assimilation of data across institutions is acceptable or whether a standard culturing methodology across institutions is necessary. Level of Evidence: V

The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization.The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption.Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P.001), age60 years (P.01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences.There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

Background Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. Methods In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. Results A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. Discussion Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

Hypothesis The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. Methods A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). Results A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, –1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, –0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. Conclusion LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. Methods A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. Conclusion Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. Level of Evidence Level V, expert opinion.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. Methods A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. Conclusion Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. Level of Evidence Level V: expert opinion.

Background The study evaluates patient-reported outcomes in revision shoulder arthroplasty (RevSA) according to etiology. Methods Twenty-three consecutive RevSA (minimum 2-year follow-up) were retrospectively reviewed. Patient-reported outcome (PRO) scores and range of motion were compared by the type of revision procedure and indication. Results EQ5D-QOL, VAS-pain, ASES, and forward elevation improved after RevSA. The infection group had least improvements. Revision to a reverse total shoulder arthroplasty (RTSA) demonstrated the most improvement in VAS-pain, forward elevation, and ASES. Conclusions Revision to RTSA significantly improved PRO scores compared to hemi- or total shoulder arthroplasty. RevSA for infection demonstrated the least improvement in outcomes.

The purpose of this study was to examine the influence of topical vancomycin on cell migration and survival of tissue healing cells. Human osteoblasts, myoblasts and fibroblasts were exposed to vancomycin at concentrations of 1, 3, 6, or 12 mg/cm2 for either a 1-h or 48-h (continuous) duration. Continuous exposure to all vancomycin concentrations significantly reduced cell survival (

Background The purpose of this study was to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon (FTST) tear using formal cost-effectiveness analysis. Methods A decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected FTST tear was used to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI. Comprehensive literature search and expert opinion provided data on cost, probability, and quality of life estimates. The primary effectiveness outcome was quality-adjusted life-years (QALYs) through 2 years, with a willingness-to-pay threshold set to $100,000/QALY gained (2016 U.S. dollars). Costs and health benefits were discounted at 3%. Results Ultrasound was the least costly strategy ($1385). MRI was the most effective (1.332 QALYs). Ultrasound was the most cost-effective strategy but was not dominant. The incremental cost-effectiveness ratio for MRI was $22,756/QALY gained, below the willingness-to-pay threshold. Two-way sensitivity analysis demonstrated that MRI was favored over the other imaging strategies over a wide range of reasonable costs. In probabilistic sensitivity analysis, MRI was the preferred imaging strategy in 78% of the simulations. Conclusion MRI and ultrasound represent cost-effective imaging options for evaluation of the patient thought to have a symptomatic FTST tear. The results indicate that MRI is the preferred strategy based on cost-effectiveness criteria, although the decision between MRI and ultrasound for an imaging center is likely to be dependent on additional factors, such as available resources and workflow.

The long head of biceps tendon (LHBT) is frequently involved in rotator cuff tears and can cause anterior shoulder pain. Tendon hypertrophy, hourglass contracture, delamination, tears, and tendon instability in the bicipital groove are common macroscopic pathologic findings affecting the LHBT in the presence of rotator cuff tears. Failure to address LHBT disorders in the setting of rotator cuff tear can result in persistent shoulder pain and poor satisfaction after rotator cuff repair. Tenotomy or tenodesis of the LHBT are effective options for relieving pain arising from the LHBT in the setting of reparable and selected irreparable rotator cuff tears.

The long head of biceps tendon (LHBT) is a well-recognized cause of anterior shoulder pain. Tenotomy or tenodesis of the LHBT is an effective surgical solution for relieving pain arising from the LHBT. Cosmetic deformity of the arm, cramping or soreness in the biceps muscle, and strength deficits in elbow flexion and supination are the three most common adverse events associated with tenotomy of the LHBT. Complications associated with tenodesis of the LHBT include loss of fixation resulting in cosmetic deformity, residual groove pain, pain or soreness in the biceps muscle, infection, stiffness, hematoma, neurologic injury, vascular injury, proximal humerus fracture, and reflex sympathetic dystrophy.

The functional role of the long head of biceps in shoulder is controversial but it is well accepted as a pain generating structure. The long head of biceps can result in anterior shoulder pain after shoulder arthroplasty. Tenodesis of the long head of the biceps during shoulder arthroplasty is a safe and easy procedure, which minimizes the risk of postoperative "Popeye" deformity and anterior shoulder pain.

A Hill-Sachs lesion (HSL) is an impression fracture that is typically located in the posterior superolateral location on the humeral head and is a tell tale sign of anterior shoulder dislocation. Hill-Sach lesions are a common associated pathoanatomic finding in anterior shoulder instability but a large, clinically significant HSL is uncommon. The management of a large HSL is a challenging clinical situation in a young patient. The first priority is repair of anterioinferior capsulolabral soft tissues and restoration of glenoid arc to increase the glenoid track and this option alone is effective in most of the patients. A large HSL in presence of bipolar bone loss may require surgical management to prevent engagement. Anatomic restoration of the humeral head defect with a fresh humeral head osteochondral allograft provides anatomic stability and biology (live cartilage cells) and is a viable option for treatment of large HSL. We reserve prosthetic option (arthroplasty) for elderly patients with large HSLs or as a salvage option for failed allograft reconstruction of HSL in young patient with arthritis.

The acromioclavicular (AC) and coracoclavicular (CC) ligaments are the principal stabilizers of the AC joint. AC joint injuries are common in contact sports and are graded according to the severity of injury to AC and CC ligaments and radiographic displacement of the AC articulation. Complete AC joint dislocation involves disruption of the AC and CC ligaments and the deltotrapezial fascia. Lower-grade injuries (types I and II) are initially managed nonoperatively and most patients do well. Operative treatment is indicated for higher-grade dislocations (types IV, V and VI). The management of type III AC joint dislocation is controversial and a matter of ongoing debate. A large number of surgical procedures and their modifications have been described in literature, but there is no consensus on the ideal procedure of choice for the treatment of AC joint dislocation. The anatomic coracoclavicular reconstruction (ACCR) restores stability to the AC joint by reconstructing the CC and AC ligaments. In this surgical technique, allograft or autograft tissue is used as biologic graft, and a suture or tape is used as a nonbiological method of fixation. Postoperative immobilization and rehabilitation is an essential component of the AC joint reconstructive process. In this article, we describe in detail the indications, surgical technique, postoperative rehabilitation, and outcomes of open anatomical CC ligament reconstruction for AC joint dislocation.

Most distal bicep tendon ruptures occur in middle-aged men (fourth decade). The most common mechanism of distal biceps tears is sudden eccentric loading of an actively contracting biceps (lifting or pushing heavy load) resulting in tendon failure usually at the tendon-bone junction. The indications for surgical reconstruction, type of surgical approach, and the fixation techniques for the distal biceps tendon are areas of ongoing debate. Nonoperative treatment results in modest loss of elbow strength in supination. Primary repair of a complete distal biceps tear in acute stages results in a predictable recovery of elbow supination and flexion strength but carries a risk of heterotopic ossification and neurologic injury. Heterotopic ossification is more commonly described with a 2-incision technique. Nerve palsy is common with single-incision approach and is usually transient and self-limiting. Primary repair in a chronic distal biceps tear is difficult and often requires augmentation with an autograft or allograft. Biomechanical cadaveric studies demonstrate that cortical button provides a consistent higher load to failure compared with other techniques for fixation of distal biceps. Our preferred method for the repair of acute distal biceps tendon tear is a single anterior skin incision technique with hybrid fixation, which combines a cortical button using a tension slide technique and interference screw fixation. Improvement in fixation techniques of the torn tendon to bone allows for early active range of motion and is our preferred mode of rehabilitation.

The purpose of this study was to investigate the influence of combined inhibition of receptor activator of nuclear factor kappa-B ligand (RANKL) and bone morphogenetic protein (BMP) activity in a mixed lytic/blastic prostate cancer lesion in bone. Human prostate cancer cells (C4 2b) were injected into immunocompromised mice using an intratibial injection model to create mixed lytic/blastic lesions. RANK-Fc, a recombinant RANKL antagonist, was injected subcutaneously three times a week (10 mg/kg) to inhibit RANKL and subsequent formation, function and survival of osteoclasts. Inhibition of BMP activity was achieved by transducing prostate cancer cells ex vivo with a retroviral vector expressing noggin (retronoggin; RN). There were three treatment groups (RANK-Fc treatment, RN treatment and combined RN and RANK-Fc treatment) and two control groups (untreated control and empty vector control for the RN treatment group). The progression of bone lesion and tumor growth was evaluated using plain radiographs, hindlimb tumor size, 18F-Fluorodeoxyglucose and 18F-fluoride micro PET-CT, histology and histomorphometry. Treatment with RANK-Fc alone inhibited osteolysis and transformed a mixed lytic/blastic lesion into an osteoblastic phenotype. Treatment with RN alone inhibited the osteoblastic component in a mixed lytic/blastic lesion and resulted in formation of smaller osteolytic bone lesion with smaller soft tissue size. The animals treated with both RN and RANK-Fc demonstrated delayed development of bone lesions, inhibition of osteolysis, small soft tissue tumors and preservation of bone architecture with less tumor induced new bone formation. This study suggests that combined inhibition of the RANKL and the BMP pathway may be an effective biologic therapy to inhibit the progression of established mixed lytic/blastic prostate cancer lesions in bone.