Predictive factors for postoperative outcomes after reverse shoulder arthroplasty: a systematic review.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has increased at a greater rate than other shoulder procedures. In general, clinical and functional outcomes after RTSA have been favorable regardless of indication. However, little evidence exists regarding patient specific factors associated with clinical improvement after RTSA. Predicting postoperative outcomes after RTSA may support patients and physicians to establish more accurate patient expectations and contribute in treatment decisions. The aim of this study was to determine predictive factors for postoperative outcomes after RTSA for patients with degenerative shoulder disorders. METHODS: EMBASE, PubMed, Cochrane Library and PEDro were searched to identify cohort studies reporting on predictive factors for postoperative outcomes after RTSA. Authors independently screened publications on eligibility. Risk of bias for each publication was assessed using the QUIPS tool. A qualitative description of the results was given. The GRADE framework was used to establish the quality of evidence. RESULTS: A total of 1986 references were found of which 11 relevant articles were included in the analysis. Risk of bias was assessed as low (N = 7, 63.6%) or moderate (N = 4, 36.4%). According to the evidence synthesis there was moderate-quality evidence indicating that greater height predicts better postoperative shoulder function, and greater preoperative range of motion (ROM) predicts increased postoperative ROM following. CONCLUSION: Preoperative predictive factors that may predict postoperative outcomes are: patient height and preoperative range of motion. These factors should be considered in the preoperative decision making for a RTSA, and can potentially be used to aid in preoperative decision making. LEVEL OF EVIDENCE: Level I; Systematic review.

Quantifying the integrated physiological effects of endothelin-1 on cardiovascular and renal function in healthy subjects: a mathematical modeling analysis.

Endothelin-1 (ET-1) is a potent vasoconstrictor with strong anti-natriuretic and anti-diuretic effects. While many experimental studies have elucidated the mechanisms of ET-1 through its two receptors, ETA and ETB, the complexity of responses and sometimes conflicting data make it challenging to understand the effects of ET-1, as well as potential therapeutic antagonism of ET-1 receptors, on human physiology. In this study, we aimed to develop an integrated and quantitative description of ET-1 effects on cardiovascular and renal function in healthy humans by coupling existing experimental data with a mathematical model of ET-1 kinetics and an existing mathematical model of cardiorenal function. Using a novel agnostic and iterative approach to incorporating and testing potential mechanisms, we identified a minimal set of physiological actions of endothelin-1 through ETA and ETB receptors by fitting the physiological responses (changes in blood pressure, renal blood flow, glomerular filtration rate (GFR), and sodium/water excretion) to ET-1 infusion, with and without ETA/ETB antagonism. The identified mechanisms align with previous experimental studies on ET-1 and offer novel insights into the relative magnitude and significance of endothelin's effects. This model serves as a foundation for further investigating the mechanisms of ET-1 and its antagonists.

Insulin resistance, kidney outcomes and effects of the endothelin receptor antagonist atrasentan in patients with type 2 diabetes and chronic kidney disease.

BACKGROUND: Insulin resistance (IR) is a pathophysiologic hallmark of type 2 diabetes and associated with the presence of chronic kidney disease (CKD). Experimental studies suggest that endothelin-1 increases IR. We assessed the association between IR and cardio-renal outcomes and the effect of the selective endothelin receptor antagonist atrasentan on IR in patients with type 2 diabetes and CKD. METHODS: We used data from the RADAR and SONAR trials that recruited participants with type 2 diabetes and CKD [eGFR 25-75 mL/min/1.73 m², urine albumin-to-creatinine ratio of 300-5000 mg/g]. IR was calculated using the homeostatic model assessment (HOMA-IR). The association between HOMA-IR and the pre-specified cardio-renal outcomes was assessed using multivariable Cox proportional hazards regression, and effects of atrasentan on HOMA-IR by a linear mixed effect model. RESULTS: In the SONAR trial, each log-unit increase in HOMA-IR was associated with an increased risk of the composite cardio-renal outcome [hazard ratio 1.32 (95%CI 1.09,1.60; p = 0.004)], kidney outcome [hazard ratio 1.30 (95%CI 1.00,1.68; p-value = 0.048)], and the kidney or all-cause mortality outcome [hazard ratio 1.25 (95%CI 1.01,1.55; p-value = 0.037)]. After 12 weeks treatment in the RADAR trial (N = 123), atrasentan 0.75 mg/day and 1.25 mg/day compared to placebo reduced HOMA-IR by 19.1 (95%CI -17.4, 44.3) and 26.7% (95%CI -6.4, 49.5), respectively. In the SONAR trial (N = 1914), atrasentan 0.75 mg/day compared to placebo reduced HOMA-IR by 9.6% (95%CI 0.6, 17.9). CONCLUSIONS: More severe IR is associated with increased risk of cardio-renal outcomes. The endothelin receptor antagonist atrasentan reduced IR. TRIAL REGISTRATION: RADAR trial (Reducing Residual Albuminuria in Subjects With Diabetes and Nephropathy With AtRasentan): NCT01356849. SONAR trial (The Study Of Diabetic Nephropathy With AtRasentan) NCT01858532.

The prevalence and clinical course of shoulder injury related to vaccine administration (SIRVA) after COVID-19 vaccines in Dutch hospital workers.

INTRODUCTION: Shoulder Injury Related to Vaccine Administration (SIRVA) is a rare disorder characterized by persistent shoulder pain and limited range of motion presenting within 48 h after vaccine administration. With the widespread distribution of the COVID-19 vaccine, the incidence of SIRVA is expected to rise. This sudden rise in vaccine administration presents an ideal opportunity to estimate the prevalence of SIRVA and to better characterize SIRVA. OBJECTIVE: This study aims to investigate the prevalence of SIRVA following COVID-19 vaccine administration among hospital workers in the Netherlands. METHODS: A questionnaire was sent to all hospital workers from a single non-academic hospital in the Netherlands. Respondents who had active SIRVA complaints were invited for an outpatient orthopaedic clinic assessment. Data was collected on participant characteristics and physical examination including assessment of active and passive range of motion (ROM). An ultrasound was performed to identify potential abnormalities. RESULTS: 32 out of 981 (3.3%) respondents reported shoulder pain with limited ROM occurring within 48 h after vaccine administration lasting for at least 7 days. Of these 32 respondents with SIRVA, 18 (56.2%) still reported active symptoms at the time of the survey. Clinical examination of 13 (72.2%) respondents with active SIRVA complaints showed limited glenohumeral ROM, limitations in activities of daily living and injection site pain. Twelve out of thirteen (92.3%) respondents with active SIRVA complaints showed abnormalities of the soft-tissue of the shoulder on ultrasound. Physiotherapy was the most common treatment modality for persistent SIRVA complaints (38.9%). CONCLUSIONS: The prevalence of SIRVA is estimated at 3% in the adult working population. Signs and symptoms of SIRVA are variable in severity, localization and timing. Soft-tissue abnormalities is the most common clinical sign. This study contributes to clinician's knowledge on SIRVA, aiding in early recognition and treatment, which are imperative for prevention of persistent and severe shoulder pathology.

The contribution of lower-mineralized tissue to the healing of distal radius fractures assessed using HR-pQCT.

High-resolution peripheral quantitative CT (HR-pQCT) enables quantitative assessment of distal radius fracture healing. In previous studies, lower-mineralized tissue formation was observed on HR-pQCT scans, starting early during healing, but the contribution of this tissue to the stiffness of distal radius fractures is unknown. Therefore, the aim of this study was to investigate the contribution of lower-mineralized tissue to the stiffness of fractured distal radii during the first twelve weeks of healing. We did so by combining the results from two series of micro-finite element (µFE-) models obtained using different density thresholds for bone segmentation. Forty-five postmenopausal women with a conservatively-treated distal radius fracture had HR-pQCT scans of their fractured radius at baseline (BL; 1-2 weeks post-fracture), 3-4 weeks, 6-8 weeks, and 12 weeks post-fracture. Compression stiffness (S) was computed using two series of µFE-models from the scans: one series (Msingle) included only higher-mineralized tissue (>320 mg HA/cm3), and one series (Mdual) differentiated between lower-mineralized tissue (200-320 mg HA/cm3) and higher-mineralized tissue. µFE-elements were assigned a Young's Modulus of 10 GPa (higher-mineralized tissue) or 5 GPa (lower-mineralized tissue), and an axial compression test to 1 % strain was simulated. The contribution of the lower-mineralized tissue to S was quantified as the ratio Sdual/Ssingle. Changes during healing were quantified using linear mixed effects models and expressed as estimated marginal means (EMMs) with 95 %-confidence intervals (95 %-CI). Median time to cast removal was 5.0 (IQR: 1.1) weeks. Sdual and Ssingle gradually increased during healing to a significantly higher value than BL at 12 weeks post-fracture (both p < 0.0001). In contrast, Sdual/Ssingle was significantly higher than BL at 3-4 weeks post-fracture (p = 0.0010), remained significantly higher at 6-8 weeks post-fracture (p < 0.0001), and then decreased to BL-values at the 12-week visit. EMMs ranged between 1.05 (95 %-CI: 1.04-1.06) and 1.08 (95 %-CI: 1.07-1.10). To conclude, combining stiffness results from two series of µFE-models obtained using single- and dual-threshold segmentation enables quantification of the contribution of lower-mineralized tissue to the stiffness of distal radius fractures during healing. This contribution is minor but changes significantly around the time of cast removal. Its course and timing during healing may be clinically relevant. Quantification of the contribution of lower-mineralized tissue to stiffness gives a more complete impression of strength recovery post-fracture than the evaluation of stiffness using a single series of µFE-models.

Cardiorenal protective effects of canagliflozin in CREDENCE according to glucose lowering.

INTRODUCTION: Relationships between glycemic-lowering effects of sodium glucose co-transporter 2 inhibitors and impact on kidney and cardiovascular outcomes are uncertain. RESEARCH DESIGN AND METHODS: We analyzed 4395 individuals with prebaseline and postbaseline hemoglobin A1c (HbA1c) randomized to canagliflozin (n=2193) or placebo (n=2202) in The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation trial. Effects on HbA1c were assessed using mixed models. Mediation of treatment effects by achieved glycemic control was analyzed using proportional hazards regression with and without adjustment for achieved HbA1c. End points included combined kidney or cardiovascular death, end-stage kidney disease or doubling of serum creatinine (primary trial outcome), and individual end point components. RESULTS: HbA1c lowering was modified by baseline estimated glomerular filtration rate (eGFR). For baseline eGFR 60-90, 45-59, and 30-44 mL/min/1.73 m2, overall HbA1c (canagliflozin vs placebo) decreased by -0.24%, -0.14%, and -0.08% respectively and likelihood of >0.5% decrease in HbA1c decreased with ORs of 1.47 (95% CI 1.27 to 1.67), 1.12 (0.94 to 1.33) and 0.99 (0.83 to 1.18), respectively. Adjustment for postbaseline HbA1c marginally attenuated canagliflozin effects on primary and kidney composite outcomes: unadjusted HR 0.67 (95% CI 0.57 to 0.80) and 0.66 (95% CI 0.53 to 0.81); adjusted for week 13 HbA1c, HR 0.71 (95% CI 0.060 to 0.84) and 0.68 (95% CI 0.55 to 0.83). Results adjusted for time-varying HbA1c or HbA1c as a cubic spline were similar and consistent with preserved clinical benefits across a range of excellent and poor glycemic control. CONCLUSIONS: The glycemic effects of canagliflozin are attenuated at lower eGFR but effects on kidney and cardiac end points are preserved. Non-glycemic effects may be primarily responsible for the kidney and cardioprotective benefits of canagliflozin.22.

Comparing midterm clinical outcome of surgical versus ultrasound guided needle aspiration of the calcific deposits for therapy resistant calcifying tendinitis of the shoulder. A comparative cohort study.

PURPOSE: Comparing the midterm clinical outcome of surgical treatment versus ultrasound guided needle aspiration of the calcific deposits (NACD) treatment for conservative therapy resistant calcifying tendinitis (CT) of the shoulder. The hypothesis is that both surgical treatment and NACD treatment led to a comparable good clinical outcome. METHODS: A comparative cohort study was performed (n = 76). The allocation to surgical group (n = 35) or NACD group (n = 41) was the result of a shared decision-making strategy. Primary outcome was decrease in VAS for pain (pVAS). Secondary outcomes were EQ-5D index, DASH score, ASES, VAS for satisfaction, recommendation of treatment, adverse events, cross-over between groups, additional treatments, and symptomatology after care as usual. RESULTS: At midterm follow-up (5.5 years, SD 0.5 years) decrease in pVAS did not differ (p = 0.20) between two groups (60.6 mm, SD 23.3 mm vs 53.4 mm, SD 24.2 mm). Secondary clinical outcomes were also comparable. In 68.3% surgical treatment was avoided. At final follow-up none of the outcome scores differed significantly between the crossed-over patients (n = 13, 31.7%) and the initial surgical group. DISCUSSION: At midterm follow-up surgical and NACD treatment result in comparable clinical outcomes. In 68.3% a surgical treatment could be avoided. In 31.7% the patient eventually needed a surgical treatment after failed NACD treatment. After midterm follow-up these patients showed comparable good clinical outcomes. In our opinion, both NACD and surgical treatment could be considered as a next step treatment option for conservative therapy resistant CT of the shoulder. Though, one should be aware that after a midterm follow-up a high number of patients cross-over to surgical treatment after a NACD treatment.

Handheld Ultrasound Does not Replace Magnetic Resonance Imaging for Diagnosis of Rotator Cuff Tears.

Purpose: The purpose of this study was to examine the reliability and validity of handheld ultrasound (HHUS) alone versus conventional ultrasound (US) or magnetic resonance imaging (MRI) for diagnosis of rotator cuff tears and versus MRI plus computed tomography (CT) for diagnosis of fatty infiltration. Methods: Adult patients with shoulder complaints were included in this study. HHUS of the shoulder was performed twice by an orthopedic surgeon and once by a radiologist. RCTs, tear width, retraction and FI were measured. Inter- and intrarater reliability of the HHUS was calculated using a Cohen's kappa coefficient. Criterion and concurrent validity were calculated using a Spearman's correlation coefficient. Results: Sixty-one patients (64 shoulders) were included in this study. Intra-rater agreement of HHUS for assessment of RCTs (к = 0.914, supraspinatus) and FI (к = 0.844, supraspinatus) was moderate to strong. Interrater agreement was none to minimal for the diagnosis of RCTs (к = 0.465, supraspinatus) and FI (к = 0.346, supraspinatus). Concurrent validity of HHUS compared to MRI was fair for diagnosis of RCTs (r = 0.377, supraspinatus) and fair-to-moderate FI (r = 0.608, supraspinatus). HHUS shows a sensitivity of 81.1% and specificity of 62.5% for diagnosis of supraspinatus tears, 60% and 93.1% for subscapularis tears, 55.6% and 88.9% for infraspinatus tears. Conclusions: On the basis of findings in this study, we conclude that HHUS is an aid in diagnosis of RCTs and higher degrees of FI in patients who are not obese, but it does not replace MRI as the gold standard. Further clinical studies on the application of HHUS comparing HHUS devices in larger patient populations and healthy patients are required to identify its utility in clinical practice. Level of Evidence: Level III.

The association between reverse total shoulder arthroplasty neck-shaft angle on postoperative patient experienced shoulder disability: a retrospective cohort study.

Background: The neck-shaft angle (NSA) of the glenoid component used in reverse total shoulder arthroplasty (RTSA) was reduced to improve functional outcomes. This led to a decreased abduction but increased external rotation ability of patients who underwent RTSA. The impact of the decreased NSA on patient-reported shoulder disability is unknown but may have important implications for functional ability. Therefore, the aim of this study was to assess the difference in patient experienced shoulder disability between an NSA of 135° and 155° 12 months after RTSA. Methods: In this retrospective cohort study, 109 patients undergoing RTSA were included. In 68 patients, a glenoid component with an NSA of 135° was used and 41 patients received a glenoid component with an NSA of 155°. The primary outcome was Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 12 months and change scores between baseline and 12-month follow-up. Secondary outcomes were complications, Constant Murley Score, Numeric Rating Scale, active forward elevation and external rotation ability. Differences between groups were tested with t-tests or Mann-Whitney U-tests. Results: A mean difference of 10.0 in 12 months postoperative DASH scores between NSA groups was observed in favor of the 135° NSA (P = .004), which did not exceed the Minimal Clinically Important Difference. DASH changes scores did not differ between NSA groups (P = .652). Mean postoperative Constant Murley Score at 12 months was 11.1 higher in the 135° NSA group (P = .013). No differences were observed in complications (P = .721) and postoperative pain (P = .710) between groups. Difference in postoperative external rotation and forward elevation at 12 months was 10° (P = .022) and 20° (P = .046), respectively, in favor of the 135° NSA group, exceeding Minimal Clinically Important Differences. Conclusions: No clinically important difference in patient-reported shoulder disability (DASH) was found between both groups, despite a larger range of motion in the 135° NSA group. This study is the first to show the impact of NSA on patient-reported shoulder disability using the DASH.

Comparison of clinical and radiological outcomes after three different surgical treatments for resistant calcifying tendinitis of the shoulder: a short-term randomized controlled trial.

BACKGROUND: A preferable surgical treatment for patients with conservative therapy-resistant calcifying tendinitis of the shoulder is still a matter of debate. Therefore, the purpose of this study was to evaluate and compare short-term clinical and radiological results of three surgical treatment options for these patients. METHODS: A multicenter randomized trial was conducted. Sixty-nine patients were randomly assigned to receive 1. subacromial decompression (Group SAD), 2. debridement of calcifications (Group D), or 3. debridement of calcifications with SAD (Group D + SAD). Stringent inclusion and exclusion criteria were used. The primary outcome was an improvement in VAS for pain (pVAS) 6 months postoperatively. Secondary outcomes were an improvement in pVAS 6 weeks postoperatively, functional outcomes (CMS, DASH, ASES), radiological outcome, additional treatments, and complications. RESULTS: The improvement in pVAS was significant in all groups (p < 0.001) and did not differ between the groups after 6 months. Six weeks postoperatively, the improvement in pVAS was significantly (p = 0.03) less in Group SAD compared to Group D + SAD (16.5 mm, SD 19.3 mm vs 33.1 mm, SD 19.7 mm, respectively). The mean size of calcifications decreased significantly in all groups (p < 0.0001). In Group SAD, the size of the calcifications decreased less (p = 0.04) compared to Group D and Group D + SAD after 6 weeks. Group SAD received more additional treatments (p = 0.003) compared to Group D + SAD (9 vs 1), which were mainly subacromial cortisone injections. CONCLUSIONS: All patient groups showed significant pain relief and an improvement in shoulder function 6 months after surgery. However, patients in Group SAD showed inferior pain relief and less improvement in DASH score after 6 weeks. Furthermore, this group required more postoperative additional treatments. No significant differences in clinical and radiological outcomes were observed between patients in Group D compared to Group D + SAD. Therefore, an arthroscopic debridement without subacromial decompression seems to be advisable for patients with therapy-resistant calcifying tendinitis of the shoulder. Level of evidence 2, Open-Label Randomized Clinical Trial. IRB METC Zuyderland MC. Number: 14-T-112. Registered at trialregister.nl NL 4947.

Epidemiology of the diabetes-cardio-renal spectrum: a cross-sectional report of 1.4 million adults.

BACKGROUND: Type-2 diabetes (T2D), chronic kidney disease, and heart failure (HF) share epidemiological and pathophysiological features. Although their prevalence was described, there is limited contemporary, high-resolution, epidemiological data regarding the overlap among them. We aimed to describe the epidemiological intersections between T2D, HF, and kidney dysfunction in an entire database, overall and by age and sex. METHODS: This is a cross-sectional analysis of adults ≥ 25 years, registered in 2019 at Maccabi Healthcare Services, a large healthcare maintenance organization in Israel. Collected data included sex, age, presence of T2D or HF, and last estimated glomerular filtration rate (eGFR) in the past two years. Subjects with T2D, HF, or eGFR < 60 mL/min/1.73 m2 were defined as within the diabetes-cardio-renal (DCR) spectrum. RESULTS: Overall, 1,389,604 subjects (52.2% females) were included; 445,477 (32.1%) were 25- < 40 years, 468,273 (33.7%) were 40- < 55 years, and 475,854 (34.2%) were ≥ 55 years old. eGFR measurements were available in 74.7% of the participants and in over 97% of those with T2D or HF. eGFR availability increased in older age groups. There were 140,636 (10.1%) patients with T2D, 54,187 (3.9%) with eGFR < 60 mL/min/1.73m2, and 11,605 (0.84%) with HF. Overall, 12.6% had at least one condition within the DCR spectrum, 2.0% had at least two, and 0.23% had all three. Cardiorenal syndrome (both HF and eGFR < 60 mL/min/1.73m2) was prevalent in 0.40% of the entire population and in 2.3% of those with T2D. In patients with both HF and T2D, 55.2% had eGFR < 60 mL/min/1.73m2 and 15.8% had eGFR < 30 mL/min/1.73m2. Amongst those within the DCR spectrum, T2D was prominent in younger participants, but was gradually replaced by HF and eGFR < 60 mL/min/1.73m2 with increasing age. The congruence between all three conditions increased with age. CONCLUSIONS: This large, broad-based study provides a contemporary, high-resolution prevalence of the DCR spectrum and its components. The results highlight differences in dominance and degree of congruence between T2D, HF, and kidney dysfunction across ages.

[Serious shoulder injury after COVID-19 vaccination]. / Ernstige schouderproblematiek na covid-19-vaccinatie.

BACKGROUND: Since January 2021, over 24 million COVID-19 vaccines have been administered. Rarely vaccination in the deltoid muscle may lead to complications in the shoulder, called SIRVA (shoulder injury related to vaccine administration). General knowledge on SIRVA amongst doctors and other healthcare workers is lacking. However, due to the large amount of vaccinations which have been administered over the last year, SIRVA is seen more often. CASE REPORT: In this report, two cases of SIRVA due to septic arthritis and a shoulder abscess after administration of a COVID-19 vaccination, are described. CONCLUSION: SIRVA should be considered in case of shoulder complaints which persist longer than 48 hours after vaccination. Timely diagnosis and treatment by either the general practitioner or orthopaedic surgeon should be conducted to prevent long-term damage to the shoulder joint. Use of the correct vaccination technique is important to prevent the occurrence of SIRVA.

Biochemical Urine Testing of Medication Adherence and Its Association With Clinical Markers in an Outpatient Population of Type 2 Diabetes Patients: Analysis in the DIAbetes and LifEstyle Cohort Twente (DIALECT).

OBJECTIVE: To assess adherence to the three main drug classes in real-world patients with type 2 diabetes using biochemical urine testing, and to determine the association of nonadherence with baseline demographics, treatment targets, and complications. RESEARCH DESIGN AND METHODS: Analyses were performed of baseline data on 457 patients in the DIAbetes and LifEstyle Cohort Twente (DIALECT) study. Adherence to oral antidiabetics (OADs), antihypertensives, and statins was determined by analyzing baseline urine samples using liquid chromatography-tandem mass spectrometry. Primary outcomes were microvascular and macrovascular complications and treatment targets of LDL cholesterol, HbA1c, and blood pressure. These were assessed cross-sectionally at baseline. RESULTS: Overall, 89.3% of patients were identified as adherent. Adherence rates to OADs, antihypertensives, and statins were 95.7%, 92.0%, and 95.5%, respectively. The prevalence of microvascular (81.6% vs. 66.2%; P = 0.029) and macrovascular complications (55.1% vs. 37.0%; P = 0.014) was significantly higher in nonadherent patients. The percentage of patients who reached an LDL cholesterol target of ≤2.5 mmol/L was lower (67.4% vs. 81.1%; P = 0.029) in nonadherent patients. Binary logistic regression indicated that higher BMI, current smoking, elevated serum LDL cholesterol, high HbA1c, presence of diabetic kidney disease, and presence of macrovascular disease were associated with nonadherence. CONCLUSIONS: Although medication adherence of real-world type 2 diabetes patients managed in specialist care was relatively high, the prevalence of microvascular and macrovascular complications was significantly higher in nonadherent patients, and treatment targets were reached less frequently. This emphasizes the importance of objective detection and tailored interventions to improve adherence.

Stem retention and survival in revision of anatomical convertible shoulder arthroplasty to reverse arthroplasty: a Dutch registry study.

BACKGROUND: Convertible stem designs allow for stem retention during revision from anatomical to reverse shoulder arthroplasty. In some cases conversion is not possible for example due to excessive soft tissue tensioning. In these cases a total revision is necessary. The primary aim of this Dutch registry study was to evaluate the unforeseen stem reversion percentages in revision of convertible anatomical shoulder arthroplasty to reverse shoulder arthroplasty. METHODS: Shoulder arthroplasties (n = 2834) performed between 2014 and 2016 registered in the Dutch Arthroplasty Registry were selected. In 2016 94% of primary arthroplasties and 92% of revision arthroplasties were registered in the database. Arthroplasties were selected on convertibility. Mean follow-up was 2.4 years. We analysed the number of revisions for convertible and non-convertible designs. Cases with obligatory revisions as periprosthetic joint infections, stem loosening and periprosthetic fractures were excluded. Kaplan-Meier analysis was used to calculate humeral stem survival. Multivariate cox-regression analysis was used to determine risk factors for stem revision. RESULTS: The majority of procedures (respectively 90.9 and 72.1% for the convertible and non-convertible group) concerned a conversion to reverse shoulder arthroplasty (p = .02). In the convertible group, the stem was retained in 29 out of 40 patients (72.5%). Overall implant survival was 94.5% after a mean follow-up of 2.4 years. Hemiartroplasty, fracture as primary indication, previous shoulder surgery and lower age were risk factors for revision. CONCLUSIONS: Although convertible designs are gaining popularity due to their expected advantage in revision arthroplasty, surgeons should be aware that during a revision procedure in 27.5% of the patients an unforeseen stem revision is necessary.

Kidney, Cardiovascular, and Safety Outcomes of Canagliflozin according to Baseline Albuminuria: A CREDENCE Secondary Analysis.

BACKGROUND AND OBJECTIVES: The kidney protective effects of renin-angiotensin system inhibitors are greater in people with higher levels of albuminuria at treatment initiation. Whether this applies to sodium-glucose cotransporter 2 (SGLT2) inhibitors is uncertain, particularly in patients with a very high urine albumin-to-creatinine ratio (UACR; ≥3000 mg/g). We examined the association between baseline UACR and the effects of the SGLT2 inhibitor, canagliflozin, on efficacy and safety outcomes in the Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) randomized controlled trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study enrolled 4401 participants with type 2 diabetes, an eGFR of 30 to <90 ml/min per 1.73 m2, and UACR of >300 to 5000 mg/g. Using Cox proportional hazards regression, we examined the relative and absolute effects of canagliflozin on kidney, cardiovascular, and safety outcomes according to a baseline UACR of ≤1000 mg/g (n=2348), >1000 to <3000 mg/g (n=1547), and ≥3000 mg/g (n=506). In addition, we examined the effects of canagliflozin on UACR itself, eGFR slope, and the intermediate outcomes of glycated hemoglobin, body weight, and systolic BP. RESULTS: Overall, higher UACR was associated with higher rates of kidney and cardiovascular events. Canagliflozin reduced efficacy outcomes for all UACR levels, with no evidence that relative benefits varied between levels. For example, canagliflozin reduced the primary composite outcome by 24% (hazard ratio [HR], 0.76; 95% confidence interval [95% CI], 0.56 to 1.04) in the lowest UACR subgroup, 28% (HR, 0.72; 95% CI, 0.56 to 0.93) in the UACR subgroup >1000 to <3000 mg/g, and 37% (HR, 0.63; 95% CI, 0.47 to 0.84) in the highest subgroup (Pheterogeneity=0.55). Absolute risk reductions for kidney outcomes were greater in participants with higher baseline albuminuria; the number of primary composite events prevented across ascending UACR categories were 17 (95% CI, 3 to 38), 45 (95% CI, 9 to 81), and 119 (95% CI, 35 to 202) per 1000 treated participants over 2.6 years (Pheterogeneity=0.02). Rates of kidney-related adverse events were lower with canagliflozin, with a greater relative reduction in higher UACR categories. CONCLUSIONS: Canagliflozin safely reduces kidney and cardiovascular events in people with type 2 diabetes and severely increased albuminuria. In this population, the relative kidney benefits were consistent over a range of albuminuria levels, with greatest absolute kidney benefit in those with an UACR ≥3000 mg/g. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: ClinicalTrials.gov: CREDENCE, NCT02065791. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_02_22_CJN15260920_final.mp3.

Influence of humeral stem inclination in reverse shoulder arthroplasty on range of motion: a meta-analysis.

Hypothesis: The reverse shoulder arthroplasty, as introduced by Grammont, has had many modifications over time. One of these modifications was reducing the neck-shaft angle (NSA) from 155 degrees to 135 degrees. Biomechanical studies indicated that lowering the NSA increases external rotation and reduces abduction and the incidence of scapular notching. The purpose of this study was to compare range of motion, functional outcome measures, and complications in patients undergoing reverse shoulder arthroplasty, depending on the NSA, through a systematic review and meta-analysis. Methods: A literature search was conducted (articles published from January 1985 to January 2020) in the PubMed/MEDLINE, Embase, and CINAHL databases and the Cochrane library. All studies reporting outcomes after primary reverse shoulder arthroplasty for osteoarthritis and rotator cuff-related disease were included. Patients were divided into 2 groups: a medialized design (MD) with an NSA of 150-155 degrees and a lateralized design (LD) with an NSA of less than 150 degrees. Pooled effects were calculated in the form of mean differences and 95% confidence intervals (CIs). Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies - of Interventions tool for non-Randomized Controlled Trials and the Risk Of Bias 2 tool for Randomized Controlled Trials. Results: A total of 21 studies and 3134 arthroplasties were included: 1366 with an MD and 1678 with an LD. The mean age was 73.0 years (MD 74.0 and LD 72.5). A direct comparative meta-analysis was not feasible, and therefore, all data were compared using the minimal clinically important difference. The MD group demonstrated a larger improvement in abduction (56.76°, 95% CI 37.03-76.49) than the LD group (48.52°, 95% CI 28.27-68.78), however the LD group demonstrated a larger improvement in external rotation with the arm at the side (MD: 7.69°, 95% CI 0.01-15.37; LD: 16.14° 95% CI 7.18-25.09). When looking at the postoperative range of motion, the MD group had more abduction than the LD group (MD: 136.28°, 95% CI 127.36-145.20; LD: 127.77° 95% CI 117.02-138.52). Both designs had a comparable improvement in the Constant Murley score (MD 42.04 points, LD 41.14 points). Lowering the NSA was accompanied by a decrease in dislocation rate (MD: 4.6%; LD: 1.4%; P value .037) and notching rate (MD: 40.3%; LD: 17.3%; P value <.0001). Conclusion: In our analysis, lowering the NSA decreases the amount of abduction but increases the amount of external rotation. This change in range of motion is accompanied by less scapular notching and dislocations. There is no clear impact on functional outcome measures.

Editorial Commentary: Rotator Cuff Tear: Know When Not to Operate So You Don't Make It Worse.

Shoulder rotator cuff repair results in significantly improved outcomes compared with conservative treatment, but some repairs result in retear and, worst of all, enlarged retears (i.e., tears larger after surgery than primarily). Elevated serum total cholesterol and low-density lipoprotein levels and fatty infiltration of the infraspinatus are significantly related to symptomatic failed rotator cuff repair. Hypertension could also be a risk factor. In such cases, nonoperative treatment, reverse shoulder prosthesis (in older patients), or alternative joint-preserving procedures (superior capsular reconstruction, subacromial balloon spacer, multiple-tendon interposition autografts, augmentation of the long head of the biceps, or tendon transfers such as latissimus dorsi transfer and lower trapezius transfer) could be considered or are worthy of future investigation.

Extensive Achilles tendon ossification: Repair using a fascia lata graft.

Ossification of the Achilles tendon is a relatively common finding. However, a large ossification covering more than two third of the tendon is rarely seen. A 70 year old patient with a 12 cm long Achilles tendon ossification is discussed. The ossification was surgically removed and the tendon was subsequently reconstructed using a fascia lata autograft. Postoperatively the ankle was immobilised for 3 months. One year postoperatively the patient was completely recovered with the ability to stand on his toes, and minimal loss in range of motion. LEVEL OF CLINICAL EVIDENCE: 4.

The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial.

BACKGROUND: Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient's self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it. OBJECTIVE: This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed. METHODS: A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures. RESULTS: In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P<.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes. CONCLUSIONS: In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care. TRIAL REGISTRATION: Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992.