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Medicaid payer status has been shown to affect risk-adjusted patient outcomes and health care utilization across multiple medical specialties and orthopedic procedures. However, there is a paucity of data regarding the impact of Medicaid payer status on 90-day morbidity and resource utilization following primary shoulder arthroplasty (reverse total shoulder arthroplasty [rTSA], anatomic total shoulder arthroplasty [aTSA], and hemiarthroplasty [HA]). The purpose of this study was to examine 90-day readmission and reoperation rates, hospital length of stay (LOS), and direct cost following primary shoulder arthroplasty in the Medicaid population.The National Readmission Database was queried for all patients undergoing primary aTSA, rTSA, and HA from 2011 to 2016. Medicaid or non-Medicaid payer status was determined. Patient demographic characteristics and comorbidities, along with 90-day readmission, 90-day reoperation, LOS, and inflation-adjusted cost, were queried. Propensity score matching was used to control for baseline differences in cohorts that could be acting as confounders in the exposure-outcome relationship. This was achieved with 1-to-1 propensity score matching between Medicaid and non-Medicaid patients. Odds ratios (ORs) and 95% confidence intervals (CIs) for 90-day readmission and reoperation rates were calculated, and a comparison of LOS and cost was performed between the propensity score-matched cohorts.A total of 4667 Medicaid and 161,147 non-Medicaid patients were identified from the 2011-2016 National Readmission Databases. Propensity score analysis was performed, and 4637 Medicaid patients were matched to 4637 non-Medicaid patients; each group comprised 1504 rTSAs (32.4%), 1934 aTSAs (41.7%), and 1199 HAs (25.9%). Patients with Medicaid payer status yielded significant increases in the 90-day all-cause readmission rate of 11.6% vs. 9.3% (P .001; OR, 1.28 [95% CI, 1.12-1.46]), 90-day shoulder-related readmission rate of 3.3% vs. 2.3% (P = .004; OR, 1.44 [95% CI, 1.12-1.85]), and 90-day reoperation rate of 2.0% vs. 1.3% (P = .008; OR, 1.54 [95% CI, 1.12-1.94]). Furthermore, there was an increased risk of an extended LOS (ie, LOS2 days) (28.4% vs. 25.7%; P = .004; OR, 1.14 [95% CI, 1.04-1.25]) along with increased direct cost (median, $17,612 vs. $16,775; P .001).This study demonstrates that Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, LOS, and direct cost following primary shoulder arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status will be necessary to ensure good access to care for this patient population by avoiding penalties for physicians and hospital systems.

COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, posthospital disposition, and 30-day readmission rates.This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (Diagnosis-Related Group code 483, Current Procedural Terminology code 23472) from January 1, 2019, to December 18, 2020. Fracture cases were separated from nonfracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. nonwhite), Centers for MedicareMedicaid Services Hierarchical Condition Category risk score, month fixed effects, and Core-Based Statistical Area fixed effects, with standard errors clustered at the provider level, was calculated using a multivariate analysis (P .05).A total of 49,412 and 41,554 total shoulder arthroplasty (TSA) cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in reverse shoulder arthroplasty, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, P .001) when adjusted for confounders. There was a 5% increase in the discharged-home rate (88.0% to 92.7%, P .001), which was most prominent in fracture cases, with a 20% increase in discharged-home cases (65.0% to 73.4%, P .001). There was no significant change in 30-day hospital readmission rates overall (P = .20) or when broken down by individual procedures.There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift toward an outpatient surgical model can be performed safely and efficiently and has the potential to provide value.

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.Therapeutic II.

Dupuytren disease is associated with benign fibroproliferative changes to the palmar fascia of the hand sometimes resulting in progressive contractures of the fingers. The earliest descriptions of these contractures date back to the 18th century. Much has been learned about the condition since the clawing condition was first described; however, optimal treatment still poses significant challenges to modern-day surgeons. It is important to examine the treatment options for Dupuytren disease and highlight the current evidence, techniques, and cost considerations of open fasciectomy, needle aponeurotomy, and recently described minimally invasive treatment.

Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.

Functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. The aim of this systematic review was to critically compare the outcomes of three latissimus dorsi tendon transfer (LDT) techniques and two superior capsular reconstruction (SCR) techniques in treatment of FIRCTs. A systematic review of studies evaluating the outcome of FIRCT treatment was performed via a search of four databases in April 2020. Each included study was reviewed in duplicate by two reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L’Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, range of motion, patient-reported outcome measures, radiographic acromiohumeral distance (AHD), treatment failures, and revisions were recorded. Forty-six studies (1287 shoulders) met criteria for inclusion. Twenty-three studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up of 51.8 months. Ten studies (n = 369, F/U 29.2mo) reported on aLDT. Seven studies (n = 253, F/U 16.9mo) concerned SCR-Allo, and six studies (n = 160, F/U 32.mo) reported on SCR-TFL. Range of motion and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

Background Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. Methods The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. Results In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. Conclusion It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. Level of Evidence Therapeutic Level III. Disclaimer All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Introduction With the increasing incidence of total shoulder arthroplasty (TSA) being performed worldwide, there is a growing effort to reduce postoperative pain, the consumption of opioids (oral morphine equivalents [OMEs]), and subsequent in hospital length of stay. Although perioperative pain control regimens have been widely studied in patients undergoing TSA, patients continue to consume a significant quantity of opioids after surgery. In the era of an opioid epidemic, novel methods for the improvement of perioperative pain control is of utmost importance. The aim of this quality improvement initiative was to evaluate the effect of liposomal bupivacaine (LB) versus ropivacaine (RP) in interscalene peripheral nerve blockade (IPNB) in patients undergoing TSA. Methods This quality improvement initiative prospectively evaluated a consecutive group of patients undergoing TSA from June 2017 to September 2019. Patients were included if they underwent either an anatomic or reverse shoulder arthroplasty at a single institution by 1 of 2 fellowship trained surgeons. Patients were divided in to 2 temporal cohorts based on the US Food and Drug administration's approval of LB. Patients who received a RPIPNB were in the control group, while those who received a LBIPNB were in the treatment group. Outcome measures studied included average visual analog pain scores (VAS) at 24 and 48 hours in the hospital, OME's, and length of stay. Results A total of 114 patients underwent TSA and met the inclusion criteria to be included in the analysis: 58 received RPIPNB and 56 received LBIPNB. The cohorts did not demonstrate any statistically different attributes (eg, age, sex, dominance, smoking status, psychiatric disorders, diabetes, HTN, or ASA class). Difference in 24 hour and 48 hour VAS pain scores was significantly improved in the LBIPNB group as compared to the RPIPNB group (2.46 vs. 0.72, and 2.02 and −0.41, respectively P Conclusion Despite significantly improved pain scores at 24 hours and 48 hours, patients who received LBIPNB did not demonstrate a statistically significant improvement in LOS or quantity of OME's consumed. The discrepancy between subjective numeric pain scores and objective healthcare metrics is likely multifactorial, and brings to light the difficulty in determining the value of new pain regimens. In lieu of these findings, it is difficult to endorse or reject the use of LBIPNB in TSA. Without further studies demonstrating improved efficacy in reduction of opioid consumption and LOS, given the additional expense of the drug, its continued use remains uncertain. Level of Evidence Level III.

Carpal tunnel syndrome and ulnar nerve compression at the elbow (e.g., cubital tunnel syndrome) are the most common upper extremity compressive neuropa- thies treated by hand surgeons. The aim of this study was to determine demographic factors and comorbidities that can help predict those patients most likely to undergo concurrent release of both the carpal tunnel and ulnar nerve at the elbow. We hypothesized that certain comorbidities, such as diabetes, would be associated with an increased risk for the necessity of concomitant procedures.Using Truven Marketscan® database, all patients who underwent carpal tunnel release were identified from 2010 to 2017 using Current Procedural Terminology (CPT) codes. Patients were only included if they had continuous enrollment in the database for 12 months preoperatively. Preoperative comorbidities and concurrent procedures were collected us- ing CPT and ICD-9 and 10 codes. Patients who underwent simultaneous carpal tunnel and ulnar nerve at the elbow release on the same day were compared to those patients who underwent carpal tunnel release alone. Additionally, patients who underwent either procedure initially and then went on to have the other procedure at a later date were compared. Univariate analysis and binomial logistic regression were performed to assess the contribution of patient demographics and comorbidities on the necessity of simultaneous release.259,574 patients underwent carpal tunnel release surgery and were included in the study. 24,401 (7.9%) of pa- tients also underwent simultaneous ulnar nerve release at the elbow on the same day. Significant risk factors associated with the need for simultaneous release, were male gender [(Odds Ratio (OR): 2.05, Confidence Interval (CI): 2.00-2.11, p0.001)], chronic pain (OR: 1.78, CI: 1.68-1.87, p0.001), diabetes (OR: 1.29, CI: 1.25-1.33, p0.001), history of al- coholism (OR: 1.23, CI: 1.10-1.38, p0.001), chronic renal disease (OR: 1.26, CI: 1.18-1.34, p0.001), tobacco use (OR: 1.49, CI: 1.42-1.56, p0.001), and patients with congestive heart failure (OR: 1.26, CI: 1.17-1.35, p0.001). Patients with consumer driven health plans and high deductible health plans (HDHP) were 1.5 times more likely to have simultane- ous release compared to those with comprehensive plans (OR: 1.46, CI: 1.37-1.56, p0.001; OR: 1.45, CI: 1.34-1.57, p0.001; respectively). For necessity of subsequent carpal or ulnar nerve release after either primary procedure, patients with a minimum of 3 years enrollment in the database were analyzed. Of the 113,505 patients who underwent initial carpal tunnel release, 1,746 (1.5%) went on to undergo release of the ulnar nerve at the elbow. Of the 12,673 patients who had initial ulnar nerve releases at the elbow, 721 (5.7%) required additional release of the carpal tunnel.Identification of patient demographic factors and comorbidities that can help predict the likelihood of si- multaneous release of both the carpal tunnel and ulnar nerve at the elbow can help direct management of these patients. Combining the two procedures can help save resources, minimize patient burden, and help reduce excess health care utilization.

Background First carpometacarpal (CMC) osteoarthritis or trapeziometacarpal osteoarthritis is a common debilitating hand condition. No one surgical technique has demonstrated superiority in managing this disease. Purpose This study performed a systematic review of arthroscopic techniques for treating first CMC arthritis to assess the effectiveness of different arthroscopic techniques. Methods Grip strength, pinch strength, visual analog scale, the Disability of Arm, Shoulder, and Hand (DASH) score, range of motion (ROM), and complications were recorded. Two subgroup analyses were performed, comparing outcomes of (1) trapeziectomy of any type versus debridement alone and (2) trapeziectomy alone versus interposition versus suspension techniques. Results Preoperative and postoperative scores significantly improved for DASH scores and pain at rest and with activity with variable improvements in ROM. Complications occurred in 13% of cases in publications that reported complications. When comparing studies that utilized techniques with any type of trapeziectomy to debridement alone, only the trapeziectomy subgroup showed significant improvements in pain. When comparing trapeziectomy alone to interposition and suspension techniques, mean DASH scores and pain levels significantly improved in interposition and suspension subgroups. Conclusions The existing literature describes a predominantly female population with Eaton-Littler stage II and III disease. In the subgroup analysis, arthroscopic techniques involving a trapeziectomy seem to be more effective at lowering pain scores compared to techniques involving debridement alone. Likewise, interposition and suspension techniques may show improved outcomes compared to techniques involving trapeziectomy alone. Level of evidence This is a Level III study.

Purpose The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced radiocarpal arthritis that failed conservative management and to assess postoperative outcomes. Methods We reviewed articles from PubMed, EMBASE, and Web of Science from inception through December 2019. We identified complete manuscripts written in English reporting on RL or RSL arthrodesis for treatment of wrist pathology that included the primary outcomes (pain or grip strength) and at least 2 secondary outcomes (range of motion, patient-reported outcomes, or nonunion). Data pooling was used to calculate weighted averages. Results We identified 2,252 articles and selected 13 for inclusion. Across all studies, RSL arthrodesis was performed for 180 patients (49% female; 45 years old) and RL for 94 (87% female; 50 years old). Both procedures exhibited improvements in pain score and grip strength. Both cohorts demonstrated postoperative changes in flexion-extension arc, flexion, extension, ulnar deviation, supination, and pronation after data pooling. The nonunion rate for RSL was 15% versus 2% for RL, whereas the rate of progression to total wrist arthrodesis for RSL and RL was 4% and 0%, respectively. Conclusions Both RL and RSL arthrodesis can be successfully used to manage debilitating radiocarpal arthritis by affording patients with pain reduction. Each has its own benefits, in which RSL arthrodesis provides a total arc of motion within the functional demands of most activities of daily living, and RL arthrodesis has low rates of nonunion and progression to total wrist arthrodesis. Further research is needed to compare the 2 surgeries directly and prospectively in comparable patient groups. Type of study/level of evidence Therapeutic III.

Introduction The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures. Methods A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits. Results Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. Discussion Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions. Level of evidence Level III observational cohort study.

Purpose To evaluate factors that predict the use of electrodiagnostic testing (EDS) for patients undergoing carpal tunnel release (CTR). Methods In this cohort study, we analyzed 553 patients who underwent primary CTR from 8 practices between July 1, 2019 and December 1, 2019 by 32 surgeons in the Michigan Collaborative Hand Initiative for Quality in Surgery (M-CHIQS). The M-CHIQS is a collaborative initiative aimed at improving quality in hand surgery. Demographic and clinical characteristics were collected, including the 6-item carpal tunnel symptoms scale (CTS-6) scores and EDS timing. Multilevel logistic regression was used to assess practice and surgeon variation in EDS use related to clinical diagnostic criteria. Results Of the 553 patients who underwent CTR during the study period, 461 (83.3%) received preoperative EDS. After controlling for patient clinical and demographic characteristics, CTS-6 scores were not associated with receiving any preoperative EDS (lower probability of CTS: odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.59–1.51), preconsultation EDS (low probability of CTS: OR, 1.00; 95% CI, 0.73–1.38), or postconsultation EDS (low probability of CTS, OR, 1.10; 95% CI, 0.77–1.60). For use of any EDS, 9.3% of the variation in testing was explained at the practice level and 31.1% of the variation in testing was explained at the surgeon level. Conclusions Variation in EDS use is explained primarily at the practice and surgeon levels and is not related to patient clinical criteria. We recommend that providers and practices assess their use of preoperative EDS and limit its use to patients with an unclear clinical CTS diagnosis, as stated in current clinical practice guidelines. Likewise, providers should be encouraged to use the CTS-6 before prescribing EDS. Clinical relevance Limiting the use of EDS to patients with an unclear clinical diagnosis of CTS will reduce costs and improve patient care by eliminating the discomfort and time associated with this test.

The incidence of total shoulder arthroplasty (TSA) continues to increase. Although researchers expect preoperative depression to influence outcomes following primary hip and knee arthroplasty, there is a paucity of data on this relationship after primary TSA. The purpose of this study was to define the relationship between a preoperative diagnosis of depression and postoperative outcomes following TSA.This was a level III retrospective cohort study. We identified patients undergoing TSA between 2009 and 2017 from the Truven MarketScan database and created 2 cohorts, patients with and without depression. We included patients who were continuously enrolled in the database for 1 year preoperatively and postoperatively. We collected demographic data, complication data, and health care utilization factors and then performed statistical analysis comparing complication and health care utilization between cohorts. This analysis controlled for baseline patient demographic, comorbid, and surgical factors.We included 22,623 patients undergoing TSA in this study. Of these, 3209 (14%) had a preoperative diagnosis of depression. Multivariate analysis demonstrated that the following were more common in patients with depression: sepsis (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.14-3.65; P = .022), revision within 1 year (OR, 1.92; 95% CI, 1.45-2.55; P.001), prosthetic joint infection within 1 year (OR, 1.41; 95% CI, 1.04-1.90; P = .025), return to the operating room for irrigation and débridement (OR, 2.72; 95% CI, 1.67-4.42; P.001), prosthetic complication (OR, 1.54; 95% CI, 1.26-1.88; P.001), and wound complication (OR, 1.84; 95% CI, 1.2-2.79; P = .004). Similarly, patients with depression had greater health care utilization including higher odds of non-home discharge (OR, 1.43; 95% CI, 1.3-1.57; P.001), 90-day readmission (OR, 1.55; 95% CI, 1.3-1.86; P.001), 90-day emergency department visit (OR, 1.39; 95% CI, 1.23-1.57; P.001), and extended length of stay (≥3 days; OR, 1.23; 95% CI, 1.12-1.36; P.001).Depression prior to TSA is common and is associated with increased risk of complications and increased health care utilization following TSA. Determining whether this is a modifiable risk factor requires further investigation.

Background There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA). Methods The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025. Results Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA. Conclusions The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

Distal radius fractures (DRFs) are among the most common fractures in the United States. Despite their high incidence, there is no consensus on the optimal type of cast or splint to treat these fractures. The purpose of this systematic review is to evaluate the available literature pertaining to the outcomes for different constructs used to conservatively treat DRFs. A literature search of PubMed, Medline, and Embase was conducted to identify research comparing the outcomes of various immobilization mechanisms. In particular, endpoints included complications (eg, loss of reduction, pain), radiographic outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. A total of 1655 articles were identified during the literature search, and 22 ultimately fulfilled inclusion criteria. These 22 studies included 1826 conservatively treated DRFs. The different immobilization mechanisms were divided into 8 groupings: above-elbow casts, above-elbow splints, below-elbow casts, below-elbow splints, gutter or spica casts, gutter or spica splints, dorsal-volar splints, and dorsal splints. Qualitative review of the studies determined that below-elbow constructs result in equal or better functional and radiologic outcomes when compared with above-elbow constructs. Meta-analysis demonstrated that a statistically significant difference ( P = .04) existed in the incidence of loss of reduction between the immobilization constructs, although post hoc analysis did not detect significant differences between 2 particular constructs.

The purpose of this study was to compare postoperative pain following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients receiving an adductor canal block (ACB) with ropivacaine (R-ACB) or liposomal bupivacaine (LB-ACB). The secondary purpose was to compare opioid consumption. A prospective cohort study of patients undergoing ACLR at an academic medical center was conducted from November 1, 2018 to November 21, 2019. The first cohort received R-ACB and 30 tablets of 5/325 mg oxycodone/acetaminophen. After June 13, 2019, the second cohort received LB-ACB and 20 tablets of 5/325 mg oxycodone/acetaminophen with the reduction in opioids prescribed resulting from a hospital quality improvement initiative to decrease narcotic consumption. From postoperative days 0 through 6, pain was assessed thrice daily using a numeric rating scale. Total postoperative opioid consumption was reported via tablet count and converted to oral morphine equivalents (OMEs). During this period, 165 subjects underwent ACLR, and 126 met the eligibility criteria (44.4% female, 55.6% male; mean ± standard deviation: 28.7 ± 13.7 years). Sixty-six (52.4%) received LB-ACB, and 60 (47.6%) received R-ACB (p = 0.53). The most common graft utilized was quadriceps autograft (63.6% LB-ACB; 58.3% R-ACB, p = 0.76). Mean postoperative pain scores were similar between groups during the entire postoperative period (p ≥ 0.08 for POD 0–6). While postoperative opioid consumption was lower among patients receiving LB-ACB (median OME [interquartile range]: 28.6 [7.5–63.8] vs. 45.0 [15.0–75.0], p = 0.023), this only amounted to an average of 2.2 tablets. Patients receiving LB-ACB in the setting of ACLR reported similar postoperative pain compared with those receiving R-ACB. Despite the second aim of our study, we cannot make conclusions about the effect of each block on opioid consumption given that each cohort received different numbers of opioid tablets due to institutional pressure to reduce opioid prescribing. As few patients completed their opioid prescriptions or requested refills, further reduction in prescription size is warranted. Future studies are necessary to further elucidate the effect of LB-ACB versus R-ACB on postoperative pain and opioid consumption after ACLR.

Introduction Shoulder arthroplasty (SA) provides pain relief and functional improvement in patients with shoulder arthritis. With increasing incidence of SA, there is a growing effort to risk-stratify these patients to diminish complication rates. The aim of this study is to quantify complication risk, resource utilization, and mortality of patients with chronic kidney disease (CKD) who are undergoing SA (both non-dialysis dependent and dialysis dependent) to identify any disease-severity relationship with delirious SA outcomes. Methods We queried the Nationwide Inpatient Sample database for patients with and without diagnosis of CKD SA from 2007 to 2015. Additional patient comorbidities were stratified using the Elixhauser comorbidity index. Outcomes of interest include mortality, non-surgical and surgical complications, and resource utilization metrics. Multivariate logistical regression was run to determine odds ratios for development of these complications in the non-dialysis dependent (NDD) and dialysis-dependent cohort (DD). Results Between 2007 and 2015, the prevalence of patients with CKD undergoing SA more than doubled. On univariate analysis, mortality, non-surgical and surgical complications, and all resource-utilization metrics were increased in CKD patients, with a direct disease-severity-dependent relationship; the rate of inpatient mortality in the DD cohort after SA was 32 times higher than patients without CKD (p Conclusion Patients with CKD undergoing SA had a far greater risk of mortality, development of postoperative surgical and non-surgical complications, and resource utilization metrics during the postoperative inpatient stay after SA. CKD is an independent risk for a detrimental postoperative course after SA, and this relationship is worsened in patients requiring dialysis. The CKD population represents a potentially hazardous candidate for elective SA. Level of evidence Level III

BACKGROUND: Despite the widespread use of arthroscopic rotator cuff repair (aRCR), there remains considerable debate on the benefits of a dual-row vs. a single-row (SR) repair technique. This study compares operative time of a knotless SR technique with transosseous equivalent (TOE) dual-row technique for aRCR and defines patient-specific factors that affect operative time. METHODS: Data from 118 patients who underwent aRCR with a knotless SR technique was compared with data from 95 patients who underwent aRCR with a TOE technique by a single surgeon between 2014 and 2018. Baseline patient demographic information and operative time were recorded and compared between the 2 groups. Subgroup analysis was performed to determine if demographic information or tear size influenced operative time. RESULTS: The average operative time in the SR group was 75.68 minutes and the average operative time in the TOE group was 89.24 minutes (P < .001). When controlling for all concomitant procedures, the operative time in the TOE group was 8.1 minutes longer than the SR group (P =.029). Average tear size in an anterior-posterior direction was larger in the TOE group vs. the SR group, 26.09 mm vs. 15.18 mm (P < .001). CONCLUSION: When controlling for concomitant procedures, a knotless, TOE dual-row technique for aRCR adds an average of 8 minutes’ operative time compared with a knotless SR technique. This was despite a significantly larger tear size in the TOE group. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Comparison; Treatment Study

The biceps brachii myotendinous unit, particularly the long head of the biceps tendon and its labral attachment, is a common cause of shoulder and arm pain. Its complex anatomy and normal variations can present a challenge when interpreting MR images. The purpose of this manuscript is to review the proximal biceps anatomy, variants, pathology, and post-operative appearance as seen on MRI. Recent data regarding the accuracy of clinical examination and MRI will be summarized.

BACKGROUND: The Short Form-12 (SF-12) was developed as a shorter version of the SF-36, yet there has been limited validation of its reliability at measuring postoperative changes. The purpose of this study was to determine if the SF-12 could safely substitute for the SF-36 in measuring postoperative change in lumbar spine surgery patients and if the condition specific (Oswestry Disability Index [ODI]) or pain (visual analog scale [VAS]) instruments, provided additional utility. METHODS: A total of 972 patients from a single center who underwent lumbar spine surgery for a predominant symptom of radiating leg pain with (n = 237) or without (n = 735) fusion and prospectively completed both SF-36 and ODI instruments before and after surgery were included. The SF-12 score was calculated from the appropriate subset of SF-36 responses. The absolute sensitivity and the intraclass correlation coefficient were calculated. Reliability of each instrument to measure preoperative to postoperative change was calculated as the standardized response mean. RESULTS: The SF-12 and SF-36 demonstrated a strong correlation with each other ([0.97, P < .001] and [0.93, P < .001], respectively) preoperatively and postoperatively. The SF-12 and SF-36 scores were moderately to strongly inversely correlated with the ODI. The ODI showed greater reliability at measuring change than the SF-12 for both fusion (0.94 versus 0.72) and nonfusion (0.81 versus 0.33) lumbar surgery patients. CONCLUSIONS: The SF-12 was as effective as the SF-36 to measure general health status in lumbar spine surgery patients, and both were moderate to strong predictors of ODI preoperatively and postoperatively, but lack the reliability to detect change seen with the ODI or VAS after surgical intervention. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: These data suggest that the SF-12 is a valid substitute for the SF-36 to measure postoperative outcomes changes, but that the ODI should continue to be used to measure condition specific changes in function.

BACKGROUND As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:. Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States. Methods:. The National Inpatient Sample (NIS) was queried to count all patients who underwent total shoulder arthroplasty (TSA), including both anatomic and reverse TSA, and hemiarthroplasty between 1988 and 2017. The counting method was used to calculate the current prevalence of TSA and hemiarthroplasty using age and sex-specific population and mortality data from the U.S. Census Bureau. Results:. In 2017, an estimated 823,361 patients (95% confidence interval [CI], 809,267 to 837,129 patients) were living in the United States with a shoulder replacement. This represents a prevalence of 0.258%, increasing markedly from 1995 (0.031%) and 2005 (0.083%). Female patients had a higher prevalence at 0.294% than male patients at 0.221%. Over 2% of people who were ≥80 years of age in the United States were living with a shoulder replacement. Furthermore, approximately 60% of patients living with a shoulder replacement had undergone the operation between 2013 and 2017. The incidence of revision shoulder arthroplasty is increasing on an annual basis, with 10,290 revision procedures performed in 2017, costing the U.S. health-care system $205 million. Conclusions:. The prevalence of shoulder arthroplasty in the United States has markedly increased over time. This trend will likely continue given increasing life expectancies and exponentially increasing shoulder arthroplasty incidence rates. Most patients do not have long-term follow-up, and revision shoulder arthroplasty rates are increasing, a trend that is projected to continue. The data from our study highlight the enormous public health impact of shoulder replacement and shed light on a potentially increasing revision burden.

Purpose Carpal tunnel syndrome is a common condition, with well-defined diagnostic and treatment guidelines. Despite these guidelines, continued variation in care exists, with providers variably using diagnostic tests and nonsurgical treatment modalities prior to surgery. The purpose of this study was to evaluate the variation and cost associated with the diagnosis and nonsurgical treatment of patients prior to undergoing carpal tunnel release. Methods We queried the Truven MarketScan database to identify patients who underwent carpal tunnel release from 2010 to 2017. Patients were identified using common current procedural terminology codes and included if they were enrolled in the database for a minimum of 12 months prior to surgery to allow all preoperative data to be captured. All associated current procedural terminology codes during the 1-year preoperative period were refined to codes related to median neuropathy and categorized as office visits, diagnostic imaging (x-ray, ultrasound, and magnetic resonance imaging), electrodiagnostic testing, injections, occupational or physical therapy, durable medical equipment, and preoperative laboratory tests. Results In total, 378,381 patients were included in the study. A per-patient average cost of $858.74 was spent on preoperative workup and nonsurgical treatment. Electrodiagnostic testing represented 44.6% of the cost, and office visits represented 31.9%. Regarding nonsurgical treatment, 16.1% of the patients received an injection during the 1-year preoperative period, 26.8% received a medical brace, and 6.6% used physical therapy. When analyzed based on age group, the per-patient average cost for patients aged 70 years or older was significantly less than those younger than 70 years ($723.92 vs $878.76). Conclusions Despite robust clinical practice guidelines and high volumes, significant variation in presurgical care exists. These data are useful to begin to critically analyze the causes of variation in the diagnosis and treatment of carpal tunnel syndrome and move toward a more effective, efficient, and informed treatment strategy. Type of study/level of evidence Economic/decision analysis II.

Introduction: Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods: The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results: Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group (P

Background Recent studies suggest increased complications when surgery closely follows corticosteroid injection. The purpose of this study was to understand the occurrence of surgical site infection (SSI), wound complications, and reoperation rates after carpal tunnel release (CTR) when corticosteroid injections were given within 180 days preoperatively. Methods Data were collected from the Truven MarketScan database from 2009 to 2018. Cohorts were created based on preoperative timing of injection (Results Overall, 223 899 patients underwent CTR. Of these, 17 391 (7.76%) had a preoperative injection in the 180 days preceding surgery. Univariate analysis demonstrated a relationship between timing of injections and noninfectious wound complications ( P = .006) and rate of 1-year reoperation ( P = .045). Univariate analysis demonstrated a relationship between number of injections and 1-year reoperation ( P < .001). On multivariate analysis, those receiving injections within 30 days preoperatively had increased rates of SSI ( P = .034) and noninfectious wound complications ( P = .006) compared with those with no injection or at other time points. Patients with 2 ( P = .002) or 3 or more injections ( P < .001) in the 180-day preoperative period had increased odds of 1-year reoperation. Conclusion Our study suggests increased risk of SSI, wound complications, and 1-year reoperation when corticosteroid injections are administered in the 30-day preoperative period. In addition, multiple steroid injections may increase the risk of 1-year reoperation.