Background The substantial increase in the utilization of shoulder arthroplasty in the United States during the past decade is partly attributable to the growing acceptance of reverse shoulder ...arthroplasty (RSA). This study compared the national utilization of and indications for shoulder hemiarthroplasty, total shoulder arthroplasty (TSA), and RSA. Methods The Nationwide Inpatient Sample was used to identify shoulder arthroplasty procedures performed in the United States in 2011. Indicating diagnoses, demographics, and hospital characteristics were identified for each shoulder arthroplasty procedure. Multivariable regression identified factors associated with long hospital stays. Results An estimated 66,485 shoulder arthroplasty procedures were identified (33% RSA, 44% TSA, and 23% hemiarthroplasty). Common diagnoses for RSA were rotator cuff tear and arthritis (80%) and proximal humerus fracture (10%). TSA was performed for osteoarthritis in 93% of cases. Hemiarthroplasty was performed for osteoarthritis (45%) and proximal humerus fracture (38%). One quarter of proximal humerus fractures treated with arthroplasty received RSA compared with 69.8% that underwent hemiarthroplasty. Mortality occurred in 0.08% of patients with atraumatic diagnoses but in 0.53% of patients with proximal humerus fractures ( P < .001). Older patients with comorbidities often had longer hospital stays, as did those with government insurance. Conclusions RSAs accounted for one third of all shoulder arthroplasty procedures in the United States in 2011. Whereas the majority of RSAs are performed for rotator cuff tear arthropathy, one quarter of proximal humerus fractures are treated with RSA, suggesting the strong uptake of this relatively new procedure in the United States.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background No evaluation has been done on the relationship of the critical shoulder angle (CSA) with retear after rotator cuff repair. Our purpose was to evaluate whether a higher CSA is associated ...with retear after rotator cuff repair. Methods This was a retrospective review of 76 patients who had undergone rotator cuff repair with postoperative ultrasound examination. Ultrasound findings were graded no retear (NT), partial-thickness (PT) retear, or full-thickness (FT) retear. Preoperative radiographs were used to measure CSA, glenoid inclination, lateral acromion angle, and acromion index. Results Average age was 61.9 years (45.3-74.9 years). On ultrasound examination, 57 shoulders (74.0%) had NT, 11 (14.2%) had PT retears, and 8 (10.3%) had FT retears. There was no significant difference in retear rate by age, gender, or tension of repair. Average CSA was significantly lower for the NT group at 34.3° ± 2.9° than for the FT group at 38.6° ± 3.5° ( P < .01). If CSA was >38°, the odds ratio of having an FT retear was 14.8 ( P < .01). In addition, higher CSA inversely correlated with postoperative American Shoulder and Elbow Surgeons scores ( P < .03). Average glenoid inclination was significantly lower in the NT group at 12.3° ± 2.7° compared with 17.3° ± 2.6° in the FT group ( P < .01). If glenoid inclination was >14, the odds ratio of having a FT retear was 15.0 ( P < .01). Conclusion At short-term follow-up, higher CSA significantly increased the risk of an FT retear after rotator cuff repair. Also, increasing CSA correlated with worse postoperative American Shoulder and Elbow Surgeons scores. This radiographic marker may help manage expectations for rotator cuff tear patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
The American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical ...responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty.
Questions/purposes
We asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty?
Methods
A longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed.
Results
The MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8–22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1–44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159–0.992) or the SCB for any of the anchors (p = 0.467–0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio OR, 0.96; 95% CI, 0.94–0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16–0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89–0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07–0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24–0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19–0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty.
Conclusions
Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty.
Level of Evidence
Level III, therapeutic study.
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FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Irreparable posterosuperior rotator cuff tears cause pain and impaired shoulder function. Latissimus dorsi (LD) transfer has been proven to improve shoulder function, but lower trapezius (LT) ...transfer has recently been proposed as an alternative. This study aimed to compare the biomechanics of LD and LT transfers and how they are affected by different insertion sites.
The Newcastle shoulder model was used to investigate the biomechanics of these 2 tendon transfers. Computed tomography data sets from 10 healthy subjects were used to customize the model, and virtual LD and LT transfers were performed on supraspinatus, infraspinatus, and teres minor insertion sites. Muscle moment arms and lengths were computed for abduction, forward flexion, and external rotation.
The LT yields greater abduction moment arms compared with the LD when it is transferred to the native supraspinatus and infraspinatus insertion sites. However, they become adductors when transferred to the native teres minor insertion. Both muscles show strong external rotation moment arms, except for the LT with a supraspinatus insertion. Resting muscle strains were 0.21 (±0.03), 0.12 (±0.02), and 0.06 (±0.03) for the LD and 0.70 (±0.15), 0.61 (±0.13), and 0.58 (±0.13) for the LT for the supraspinatus, infraspinatus, and teres minor insertions, respectively.
LT provided better abduction and external rotation moment arms when transferred to the infraspinatus insertion. LD performed better when transferred to the supraspinatus insertion. Overall, LT transfer showed a biomechanical advantage compared with LD transfer because of stronger abduction moment arms. However, significantly larger muscle strains after LT transfer necessitate a tendon allograft to prevent muscle overtensioning.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background:
In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain ...reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills.
Purpose:
To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution.
Study Design:
Case series; Level of evidence, 4.
Methods:
In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication.
Results:
For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median Q1, Q3, 0 0, 16), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median Q1, Q3, 37 29, 50). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal.
Conclusion:
Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.
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The effect of obesity in shoulder arthroplasty has been recently reported in the literature with different and conflicting results. This review analyzes the role of obesity on outcomes and ...complications in shoulder arthroplasty. Morbid obesity (body mass index >40 kg/m2 ), more than standard obesity, is associated with a longer operative time, higher complication rate, reoperation rate and superficial infection. Obesity does not have a detrimental effect on functional outcomes. The magnitude of functional improvement in obese patients, however, can be inferior to that in nonobese patients. Obesity and morbid obesity do not increase hospital charges.
BACKGROUND:Recent studies have found that depression is associated with increased pain and impairment following lower-extremity arthroplasty; however, this association has not been investigated for ...total shoulder arthroplasty. The objective of this study was to investigate the association between depression and patient-reported outcomes following total shoulder arthroplasty.
METHODS:A prospectively collected institutional registry was queried for consecutive patients who underwent total shoulder arthroplasty for osteoarthritis from 2007 to 2013 with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores. Revision procedures and total shoulder arthroplasty for diagnoses other than osteoarthritis were excluded. Patients with a preoperative diagnosis of depression (n = 88) formed the study cohort; control patients without a diagnosis of depression were matched to the study patients by age and sex in a 2:1 ratio (n = 176). Baseline characteristics and patient-reported outcome measures were compared between groups, as were minimum 2-year patient-reported outcomes and change in patient-reported outcomes. A multivariable regression was performed to investigate the independent effect of depression on improvement in ASES scores.
RESULTS:Except for the Short Form-12 Mental Component Summary (SF-12 MCS) scores, there were no significant differences (p > 0.05) in baseline characteristics between study patients and controls. There was a significant improvement in the ASES score for patients with depression (p < 0.0001) and controls (p < 0.0001). Patients with depression had significantly lower final ASES scores (p = 0.001) and less improvement in ASES scores (p = 0.001) and SF-12 Physical Component Summary scores (p = 0.006) as well as lower satisfaction levels at 2 years; however, the latter difference did not reach clinical importance. Depression (p = 0.018) was an independent predictor of less improvement in ASES scores.
CONCLUSIONS:Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with a clinical diagnosis of depression from undergoing total shoulder arthroplasty.
LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND:There have been few studies that have evaluated ambulatory total shoulder arthroplasty. The objectives of the present study were to investigate the current trends in ambulatory total ...shoulder arthroplasty in the United States; to characterize the rate of postoperative complications, hospital readmission, and risk factors associated with readmission; and to conduct a cost analysis comparing ambulatory total shoulder arthroplasty with matched inpatient total shoulder arthroplasty.
METHODS:A national insurance database was queried for patients who underwent anatomic total shoulder arthroplasty between the fourth quarter of 2010 and 2014. Patients undergoing ambulatory total shoulder arthroplasty and a matched group of patients undergoing inpatient total shoulder arthroplasty were identified. Complications were assessed for both groups. Risk factors for readmission within 90 days postoperatively were examined. The costs up to 30 days postoperatively were evaluated for patients who underwent ambulatory total shoulder arthroplasty and controls.
RESULTS:Included in the study were 706 patients who underwent ambulatory total shoulder arthroplasty. From the fourth quarter of 2010 to 2014, the yearly incidence of ambulatory total shoulder arthroplasty doubled. In the study, 4,459 patients who underwent inpatient total shoulder arthroplasty were matched to patients who underwent ambulatory total shoulder arthroplasty. In no instances were any complications present at a significantly higher rate in the patients who underwent ambulatory total shoulder arthroplasty. The rate of readmission was not significantly different (p > 0.05) between the 2 cohorts. The patients undergoing ambulatory total shoulder arthroplasty had significantly lower costs (p < 0.0001) at $14,722 compared with the matched controls at $18,336 in numerous itemized cost categories as well as costs related to diagnosis-related groups.
CONCLUSIONS:In appropriately selected patients, ambulatory total shoulder arthroplasty is a viable and safe practice model. Ambulatory total shoulder arthroplasty also offers significant cost savings compared with inpatient total shoulder arthroplasty in matched patients.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background Rotator cuff tendons heal to bone with interposed scar tissue, which makes repairs prone to failure. The purpose of this
study was to determine if the application of bone marrow-derived ...mesenchymal stem cells (MSCs) can improve rotator cuff healing
after repair.
Hypothesis Application of MSCs to the repair site will result in superior results compared with controls on histologic and biomechanical
testing.
Study Design Controlled laboratory study.
Methods Ninety-eight Lewis rats underwent unilateral detachment and repair of the supraspinatus tendon; 10 rats were used for MSC
harvest. Eight animals were used for cell tracking with Ad-LacZ. The remaining animals received either 10 6 MSCs in a fibrin carrier, the carrier alone, or nothing at the repair site. Animals were sacrificed at 2 and 4 weeks for
histologic analysis to determine the amount of fibrocartilage formation and the collagen organization at the insertion. Biomechanical
testing was also performed.
Results Specimens treated with Ad-LacZâtransduced MSCs exhibited more β-galactosidase activity at the repair site compared with controls
at both 2 and 4 weeks, although activity at 4 weeks was less than that at 2 weeks. There were no differences in the amount
of new cartilage formation or collagen fiber organization between groups at either time point. There were also no differences
in the biomechanical strength of the repairs, the cross-sectional area, peak stress to failure, or stiffness.
Conclusion The addition of MSCs to the healing rotator cuff insertion site did not improve the structure, composition, or strength of
the healing tendon attachment site despite evidence that they are present and metabolically active.
Clinical Relevance A biologic solution to the problem of tendon-to-bone healing in the rotator cuff remains elusive. The repair site may lack
the cellular and/or molecular signals necessary to induce appropriate differentiation of transplanted cells. Further studies
are needed to determine if cell-based strategies need to be combined with growth and differentiation factors to be effective.
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