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Background: Compared with symptomatic bone marrow edema (BME) associated with stress fractures, asymptomatic BME seen on magnetic resonance imaging (MRI) is a phenomenon that has been described in high-level athletes and is thought to be related to bone adaptation to biomechanical loading unique to each sport. However, the prevalence, natural history, and management of these lesions remain poorly understood, particularly in dance, which places tremendous stress on the feet and ankles. Purposes/Hypothesis: The purposes of this study were to (1) determine the prevalence of asymptomatic BME in the talus before the start of the performance season, (2) identify contributing demographic and training factors, and (3) compare the radiological evidence of talar BME with validated functional foot and ankle scores. We hypothesized that talar BME would be highly prevalent among asymptomatic professional dancers. Study Design: Case series; Level of evidence, 4. Methods: A total of 14 professional ballet dancers (6 female and 8 male; mean age, 24 years) were included in this 2-year prospective study. For each participant, we recorded complete medical and surgical history along with scores on the Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Disability Index. Bilateral foot and ankle 3.0-T MRI scans without contrast were completed before the start of the performance season and were evaluated for BME of the talus using the Fredericson criteria. Results: Evidence of talar BME was seen in 15 of the 28 (54%) ankles examined and in 9 of 14 (64%) dancers. We found that 6 dancers demonstrated bilateral talar BME, 3 dancers demonstrated unilateral BME, and 5 dancers demonstrated no evidence of BME. The most common location of BME was the posterior talus, seen in 8 of 15 (53%) ankles. No statistically significant differences were noted in dancers with versus those without talar BME with regard to functional scores, demographic characteristics, or weekly training hours. Conclusion: Asymptomatic talar BME was highly prevalent (64%) in professional ballet dancers and tended to occur posteriorly. Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions.

Background Post-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures. Methods Using the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results. Results From 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had ‘Mild Systemic Disease’ (ASA 2), 20,872 (62.6%) patients had ‘Severe Systemic Disease’ (ASA 3), and 6,006 (18.1%) had ‘Life Threatening Disease’ (ASA 4/5). The majority of patients were brought in from a ‘Home’ setting, while 10.4% of patients were admitted from a ‘Long-Term Care’ setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC. Discussion Discharge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables. Level of evidence Level III, Retrospective Cohort Design, Observational Study

Background: Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure. Purpose: To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test. Results: In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet ( P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion ( P = .047) and broken, loose, or improperly placed screws ( P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport ( P < .001), return to sport at the same level ( P < .001), incidence of subluxation ( P = .003) or positive apprehension ( P = .002), and revision surgery for recurrent instability ( P = .027). Conclusion: Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

BACKGROUND Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR. METHODS Adult patients undergoing arthroscopic RCR were prospectively enrolled and randomized to one of two groups. The control received our institution's standard-of-care pain protocol, including oxycodone-acetaminophen 5 to 325 mg on discharge. The ketorolac group received the standard-of-care protocol, intravenous ketorolac at the completion of the procedure, and oral ketorolac on discharge. Pain and functional outcome scores and narcotic utilization were recorded three times per day for the first 5 days after surgery. Repeat magnetic resonance imaging was done at least 6 months postoperatively. RESULTS In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7 ± 10.6 years, and 66.7% of patients were male. No differences were observed in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 versus 8.82, P < 0.001). No difference was observed in functional outcome scores at up to 6 weeks postoperatively between the two groups. No difference was observed in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. Twenty-two of 39 patients underwent repeat magnetic resonance imaging at a mean of 7.9 months postoperatively, of which 5 (22%) demonstrated a retear of their rotator cuff. No significant difference was observed between the ketorolac and control groups in the rate of retear (P = 1.00). DISCUSSION Adjunctive ketorolac substantially reduces narcotic utilization after arthroscopic RCR.

Background Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. Methods In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents’ prescribing practices, and methods of patient counseling regarding opioid use and disposal. Results A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient’s symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. Discussion To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

Background Superior capsular reconstruction (SCR) addresses massive, irreparable rotator cuff tears in young patients. The purpose of this study was to retrospectively evaluate clinical outcomes and graft integrity in patients following SCR. Methods Thirty-four consecutive patients undergoing SCR by 2 surgeons with minimum 2-year follow-up were identified. Functional outcomes were obtained, including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and Single Assessment Numeric Evaluation (SANE) scores. Graft integrity was evaluated on magnetic resonance images (MRIs). Results Thirty-five shoulders in 34 patients were identified. Four patients underwent subsequent surgery. The mean preoperative scores were SST 21.6 ± 17.6, ASES 28.3 ± 10.1, SANE 50.6 ± 22.1, and VAS 6.6 ± 1.7. The mean postoperative outcomes were SST 79.1 ± 19.6, ASES 79.9 ± 17.4, SANE 74.3 ± 18.7, and VAS 1.5 ± 2.2. There was statistically significant improvement in SST, ASES, and VAS following SCR. MRI revealed graft failure in 62% (n = 13 of 21) of shoulders. Radiographic evidence of graft healing did not have any effect on SST, ASES, SANE, or VAS scores. Conclusion Given the high rate of graft failure without a significant difference in clinical outcomes, graft healing after SCR might not be an independent predictor of success. The improved clinical improvement in patients undergoing SCR may be due to other known beneficial aspects of the procedure, including partial rotator cuff repair, debridement, and biceps management.

BACKGROUND In patients on warfarin anticoagulation therapy, elective shoulder arthroplasty surgeons must carefully balance bleeding and embolic risks. Currently, an international normalized ratio (INR) threshold of 1.5 is supported in the setting of elective surgery. However, no previous study has investigated the optimal preoperative INR target specifically in shoulder arthroplasty. The purpose of this study was to evaluate the association of preoperative INR with rates of transfusion, complication, and readmission/revision surgery in shoulder arthroplasty. METHODS Patients who underwent elective shoulder arthroplasty were identified in a national database. The primary outcome of interest was the risk for all-cause complication at 30 days postoperatively. Major and minor complication, revision surgery, and readmission rates were also investigated. RESULTS From 2006 to 2016, 1,014 procedures were identified who had undergone elective shoulder arthroplasty with a perioperative INR lab result within 24 hours of surgery. In our cohort, 550 patients (54.2%) were women, with an average age of 71.0 ± 9.8 years. After controlling for confounders, patients with a preoperative INR > 1.5 were 18.9 times as likely to have a major complication as those with a preoperative INR ≤ 1.0 (P = 0.003). Patients with an INR of 1.25 < INR ≤ 1.5 did not have a statistically significant risk of minor or major complication in comparison with those with an INR ≤ 1.0 (P = 0.23, P = 0.67). DISCUSSION Although recent hip and knee arthroplasty literature has found that an INR < 1.25 may be an optimal preoperative INR goal, our results did not find an increased risk for bleeding and complication with an INR ≤ 1.5 for shoulder arthroplasty. These results support current guidelines recommending a preoperative INR ≤ 1.5 for shoulder arthroplasty.

Objectives: Arthroscopic rotator cuff repairs are associated with substantial postoperative pain. Traditionally, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents are associated with several side effects and a significant potential for abuse. This study evaluates the efficacy of ketorolac, a non-steroidal anti-inflammatory drug with analgesic properties, as an adjunctive agent for postoperative pain control following arthroscopic rotator cuff repair. Methods: Adult patients undergoing an arthroscopic rotator cuff repair were prospectively enrolled. Patients who met inclusion and exclusion criteria were randomized into one of two groups. The control group received our standard of care pain protocol, including oxycodone-acetaminophen 5-325 on discharge. Patients in the ketorolac group additionally received a dose of IV ketorolac intraoperatively and were prescribed a scheduled dose of oral ketorolac (10mg by mouth every six hours for three days) along with omeprazole (20mg by mouth every day for three days) for acid reflux. Visual Analogue Scale (VAS), functional outcome scores, and total narcotic utilization were recorded three times per day for the first five days after surgery. Statistically significant differences in patient demographics and comorbidities between groups were determined initially with univariate analysis. Linear mixed-effect models were then fitted for each outcome variable to evaluate the main effects of treatment group and follow-up times. Results: In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7±10.6 years and 66.7% of patients were male. There were no differences in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. (Table 1) Patients in the Ketorolac group had lower mean VAS scores and opioid utilization at all time points. (Figure 1, 2) On multivariate analysis that controls for confounding variables, patients in the ketorolac group had a mean 9.67 decrease in VAS scores in comparison to the control group, though these results were not statistically or clinically significant (Coefficient estimate= -9.67, 95% CI -25.13-5.79, p=.2202; MCID 13). (Table 3) Patients in the ketorolac group utilized significantly less narcotics, with a mean of 0.7 fewer pills of oxycodone-acetaminophen per time interval in comparison to the control group (Coefficient estimate=-0.70, 95% CI -1.005 -0.389, pConclusions: In this prospective, randomized, controlled study, the use of adjunctive intravenous and short-term oral ketorolac substantially reduced narcotic utilization following arthroscopic rotator cuff repair.