Association between same-day discharge shoulder arthroplasty and risk of adverse events in patients with American Society of Anesthesiologists classification ≥3: a cohort study.

BACKGROUND: Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. METHODS: Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. RESULTS: The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. CONCLUSIONS: In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament: Early Outcomes of Suture Anchor Repair with Suture Tape Augmentation.

Introduction The purpose of this study was to evaluate the early outcomes of thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) repair using suture anchors with suture tape augmentation. Materials and Methods Six patients underwent thumb UCL repair or reconstruction with suture tape augmentation and six patients underwent thumb UCL repair with intraosseous suture anchors between January 2013 and January 2018. The main outcome measures were range of motion, strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications. Results At final follow-up for patients who had suture tape augmentation, the average thumb MCP joint and interphalangeal (IP) joint flexion were 65 and 73 degrees, respectively. The average DASH score was 4.3. At final follow-up for patients who had intraosseous suture anchor repair, the average thumb MCP joint and IP joint flexion were 50 and 60 degrees, respectively. The average DASH score was 38. There were no complications or secondary procedures in either group. Conclusion The use of suture anchor repair with suture tape augmentation for thumb UCL injuries is a treatment option that allows for early range of motion with satisfactory early outcomes that are comparable to intraosseous suture anchor repair. Level of Evidence This is a level IV, case series article.

Association Between Rotator Cuff Tears and Superior Migration of the Humeral Head: An MRI-Based Anatomic Study.

BACKGROUND: Superior humeral migration has been established as a component of rotator cuff disease, as it disrupts normal glenohumeral kinematics. Decreased acromiohumeral interval (AHI) as measured on radiographs has been used to indicate rotator cuff tendinopathy. Currently, the data are mixed regarding the specific rotator cuff pathology that contributes the most to humeral head migration. PURPOSE: To determine the relationship between severity of rotator cuff tears (RCTs) and AHI via a large sample of magnetic resonance imaging (MRI) shoulder examinations. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A search was performed for 3-T shoulder MRI performed in adults for any indication between January 2010 and June 2019 at a single institution. Three orthopaedic surgeons and 1 musculoskeletal radiologist measured AHI on 2 separate occasions for patients who met the inclusion criteria. Rotator cuff pathologies were recorded from imaging reports made by fellowship-trained musculoskeletal radiologists. RESULTS: A total of 257 patients (mean age, 52 years) met the inclusion criteria. Of these, 199 (77%) had at least 1 RCT, involving the supraspinatus in 174 (67.7%), infraspinatus in 119 (46.3%), subscapularis in 80 (31.1%), and teres minor in 3 (0.1%). Full-thickness tears of the supraspinatus, infraspinatus, or subscapularis tendon were associated with significantly decreased AHI (7.1, 5.3, and 6.8 mm, respectively) compared with other tear severities (P < .001). Having a larger number of RCTs was also associated with decreased AHI (ρ = -0.157; P = .012). Isolated infraspinatus tears had the lowest AHI (7.7 mm), which was significantly lower than isolated supraspinatus tears (8.9 mm; P = .047). CONCLUSION: Although various types of RCTs have been associated with superior humeral head migration, this study demonstrated a significant correlation between a complete RCT and superior humeral migration. Tears of the infraspinatus tendon seemed to have the greatest effect on maintaining the native position of the humeral head. Further studies are needed to determine whether early repair of these tears can slow the progression of rotator cuff disease.

Identifying the axillary nerve during shoulder surgery: an anatomic study using advanced imaging.

BACKGROUND: The axillary nerve (AXN) is one of the more commonly injured nerves during shoulder surgery. Prior anatomic studies of the AXN in adults were performed using cadaveric specimens with small sample sizes. Our research observes a larger cohort of magnetic resonance imaging (MRI) studies in order to gain a more representative sample of the course of the AXN and aid surgeons intraoperatively. METHODS: High-resolution 3T MRI studies performed at our institution from January 2010 to June 2019 were reviewed. Four blinded reviewers with musculoskeletal radiology or orthopedic surgery training measured the distance of the AXN to the surgical neck of the humerus (SNH), the lateral tip of the acromion (LTA), and the inferior glenoid rim (IGR). Intraclass correlation coefficient was calculated to assess reliability between reviewers. The nerve location was assessed relative to rotator cuff tear status. RESULTS: A total of 257 shoulder MRIs were included. Intraclass correlation coefficient was excellent at 0.80 for the SNH, 0.90 for the LTA, and 0.94 for the IGR. All intraobserver reliabilities were above 0.80. The mean distance from the AXN to SNH was 1.7 cm (range, 0.7-3.1 cm; interquartile range, 1.38-2.00) and that from the AXN to IGR was 1.6 cm (range, 0.6-2.6 cm; interquartile range, 1.33-1.88). The mean AXN to LTA distance was 7.1 cm, with a range of 5.2-9.0 cm across patient heights; there was a large effect size related to the LTA to AXN distance and patient height with a correlation of r = 0.603 (P < .001). Rotator cuff pathology appears to affect nerve location by increasing the distance between the AXN and SNH (P = .027). DISCUSSION/CONCLUSION: The AXN is vulnerable to injury during both open and arthroscopic shoulder procedures. This injury can be either a result of direct trauma to the nerve or secondary to traction placed on the nerve with reconstructive procedures that distalize the humerus. Our study demonstrates that the AXN can be found as little as 5.6 mm from the IGR and 6.9 mm from the SNH. In addition, we illustrate the relationship between patient height and the LTA to AXN distance and complete rotator cuff tears and the SNH to AXN distance. Our study is the first to demonstrate the nerve's proximity to important surgical landmarks of the shoulder using a large sample size of high-resolution images in living human shoulders.

The Effect of Head Rotation on the Relative Vascular Anatomy of the Neck: Implications for Central Venous Access.

CONTEXT: Previous studies have shown that safe venous cannulation is difficult when the internal jugular vein (IJV) overlies the carotid artery (CA) as the probability of inadvertent arterial penetration is greatly increased. AIMS: The goal of this study was to examine the anatomical relationships of the IJV and CA as a function of the degree of head rotation in order to minimize the risk for CA puncture. SETTINGS AND DESIGN: Our study was a prospective study using a sample of 496 Emergency Department patients. METHODS AND MATERIAL: The anatomic relationships of the right and left IJVs and CAs were recorded with head rotation at three different positions. Patients who had the IJV in a 45 to 135 degree relationship to the CA were deemed to be in the high-risk zone for arterial puncture. STATISTICAL ANALYSIS: Chi square, ANOVA. RESULTS: Right IJVs were in the high risk zone for 39.5%, 47.8% and 60.9% of cases at 0, 45 and 80 degrees of head rotation, respectively (P < 0.001). Left IJVs were in the high risk zone for 59.1%, 69.2% and 80.0% at 0, 45 and 80 degrees of head rotation, respectively. (P < 0.001). CONCLUSIONS: Head rotation should be minimized during IJV cannulation to decrease the overlap of CA by IJV. Cannulation of the left IJV appears to carry a higher degree of risk as compared to the right IJV. Placing the head in neutral position, avoiding rotation, and using ultrasound guidance are recommended to minimize complications during central venous access.

Outcomes of anatomic shoulder arthroplasty in primary osteoarthritis in type B glenoids.

BACKGROUND: Primary glenohumeral osteoarthritis with posterior wear of the glenoid and posterior subluxation of the humerus (Walch type B) presents a challenge to the treating surgeon. Our hypothesis was that glenoids with biconcavity (B2) would be associated with worse outcomes (functional scores and complications) than B1 glenoids. MATERIALS AND METHODS: We retrospectively analyzed prospectively collected data on 112 anatomic total shoulder arthroplasties (104 patients) with B glenoids. Preoperative computed tomography identified 64 B1 glenoids and 48 B2 glenoids (50 and 37 available for follow-up). RESULTS: A significant difference between B1 and B2 glenoids was noted in average retroversion (11° vs. 16°; P < .001) and average posterior humeral subluxation (65% vs. 75%; P < .001). No significant difference was seen in mean age (69.5 vs. 69.2 years) or body mass index (28.5 vs. 27.4) at time of surgery. At average follow-up of 60 months (range, 23-120 months), glenoid component radiolucencies (51.6%, B1; 47.9%, B2), range of motion, preoperative and postoperative scores of the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire, and patient satisfaction were not significantly different between the 2 groups. Four revisions (4.6%) were documented for acute postoperative infection (2.3%), subscapularis failure (1.1%), and glenoid loosening (1.1%). CONCLUSIONS: Although biconcave glenoids commonly have more severe retroversion and posterior subluxation of the humerus, we were unable to find a clinical or radiographic difference in outcome of patients with B1 or B2 glenoids treated with anatomic total shoulder arthroplasty at intermediate-term follow-up. Continued clinical and radiographic follow-up of these cohorts will be necessary to assess any future divergence in outcome.