Comparative Clinical Outcomes of Reverse Total Shoulder Arthroplasty for Primary Cuff Tear Arthropathy Versus Severe Glenohumeral Osteoarthritis With Intact Rotator Cuff: A Matched-Cohort Analysis.

INTRODUCTION: The purpose of this study was to compare the short- to mid-term outcomes of patients who underwent reverse total shoulder arthroplasty (RTSA) for severe glenohumeral osteoarthritis (GHOA) with an intact rotator cuff (RC) to a matched rotator cuff arthropathy (RCA) cohort. METHODS: Between 2004 and 2014, all patients who underwent RTSA for severe GHOA with a minimum 2-year follow-up were identified. Demographic and baseline variables were extracted from the medical records. Subjects were matched in the ratio of 1:2 to RTSA subjects with RCA, while controlling for the demographic and intraoperative variables. Postoperative active forward elevation (AFE), active external rotation, American Shoulder and Elbow Surgeons Score (ASES), Visual Analog Scale (VAS), and Simple Shoulder Test were recorded. Complications and revision surgery rates were noted. Comparative multivariate analysis was performed. Preoperative Walch classification for each subject was obtained through radiograph review, and the impact of classification was assessed using one-way analysis of variance testing. RESULTS: One hundred thirty-six patients were available with mean follow-up 32.3 ± 12.3 months. Baseline range of motion and patient reported outcome scores were similar between the groups (P > 0.05), except for Simple Shoulder Test (intact rotator cuff: 5.7 ± 7.4 versus RCA: 2.4 ± 1.8, P = 0.037). The intact RC group had significantly, superior absolute outcome measures for active external rotation (P = 0.006), and SST (P = 0.048), but not for SANE (P = 0.055), VAS (P = 0.464), ASES (P = 0.084), and AFE (P = 0.099). No notable difference was observed between the groups for improvement in motion, survey scores, or complications. Walch osteoarthritis classification did not impact the outcome measurements in the severe GHOA with the intact RC group (P > 0.05). DISCUSSION: Patients who underwent RTSA for severe GHOA with intact RC demonstrate similar consistent improvement in outcomes to demographically similar patients with RCA. The severity of GHOA defined by the Walch classification did not impact the outcomes at the 2-year follow-up. LEVEL OF EVIDENCE: Level III Therapeutic Study.

Preoperative patient education and patient preparedness are associated with less postoperative use of opioids.

BACKGROUND: Because many patients are first exposed to opioids after general surgery procedures, surgical stewardship for the use of opioids is critical in addressing the opioid crisis. We developed a multi-component opioid reduction program to minimize the use of opioids after surgery. Our objectives were to assess patient exposure to the intervention and to investigate the association with postoperative use and disposal of opioids. METHODS: We implemented a multi-component intervention, including patient education, the settings of expectations, the education of the providers, and an in-clinic disposal box in our large, academic, general surgery clinic. From April to December 2018, patients were surveyed by phone 30 to 60 days after their operation regarding their experience with postoperative pain management. The association between patient education and preparedness to manage pain was assessed using χ2 tests. Education, preparedness, and clinical factors were evaluated for association with quantity of pills used using ANOVA and multivariable linear regression. RESULTS: Of the 389 eligible patients, 112 responded to the survey (28.8%). Patients receiving both pre and postoperative education were more likely to feel prepared to manage pain than those who only received the education pre or postoperatively (91% vs 68%, P = .01). Patients who felt prepared to manage their pain used 9.1 fewer pills on average than those who did not (P = .01). Fourteen patients (24%) with excess pills disposed of them. Preoperative education was associated with disposal of excess pills (30% vs 0%, P < .05). CONCLUSION: Exposure to clinic-based interventions, particularly preoperatively, can increase patient preparedness to manage postoperative pain and decrease the quantity of opioids used. Additional strategies are needed to increase appropriate disposal of unused opioids.

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings.

BACKGROUND: There is currently a paucity of non-database studies looking at safety and outcomes after outpatient shoulder arthroplasty. The purpose of this study was to report our initial safety experience with outpatient shoulder arthroplasty including 90-day complications and readmissions. Our hypothesis was that the rate of early complications after outpatient shoulder arthroplasty would be low and similar to that of inpatient procedures regardless of outpatient setting. METHODS: We analyzed 50 consecutive patients who underwent outpatient shoulder arthroplasties (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties) from 2014-2017. The readmission rate and complications were recorded. All patients were available for minimum 3-month follow-up. Preoperative and postoperative Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and visual analog scale scores were recorded. RESULTS: The average age was 56.9 ± 6.9 years; average body mass index, 29.75 ± 5.9; and average Charleston Comorbidity Index, 1.6 ± 1.2. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Only 4 occurred within the 90-day global period, and only 1 patient required readmission. Our subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). At last follow-up, all had significant improvements (P < .001) in range of motion and functional scores (American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores). No difference in the complications and functional outcomes was found between the patients based on their surgical setting. CONCLUSION: Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. No difference in complications and outcomes occurs regardless of outpatient setting.