Clinical utility of immediate postoperative radiographs following uncomplicated primary reverse shoulder arthroplasty.

BACKGROUND: It is common practice to order an immediate postoperative radiograph in the postanesthesia care unit (PACU) following reverse shoulder arthroplasty (RSA). However, with a growing emphasis on value-based care and cost-effectiveness, we question the necessity for immediate postoperative radiographs following uncomplicated, primary RSA. METHODS: From 2014-2020, patients undergoing primary RSA at a single institution by one of 3 surgeons were included in this cohort. Radiographs from the PACU and any clinic visit during the initial 3-month postoperative period were reviewed to determine if any radiographic findings from the PACU altered clinical care or decision making. RESULTS: A total of 157 patients were included in this study and 13 patients had abnormal findings during the initial 3-month postoperative period where the immediate postoperative radiograph provided clinical utility for decision making. In 9 of the 12 patients requiring revision surgery, the postoperative complication was instability. In those patients requiring revision surgery during the initial 3 months, the most common indication for primary surgery was proximal humerus nonunion. Immediate postoperative radiographs were read by the radiologist as normal/unremarkable for 100% of patients. The typical amount billed for the immediate postoperative radiograph was $544.00 per patient. CONCLUSION: Based on our findings, we see utility for an intraoperative or immediate postoperative radiograph following uncomplicated, primary RSA, especially when done as a salvage procedure for indications such as proximal humerus nonunion. However, there is low utility for obtaining an immediate postoperative radiograph in the PACU when indications include osteoarthritis or rotator cuff tear arthropathy.

Short-term outcomes associated with drain use in shoulder arthroplasties: a prospective, randomized controlled trial.

BACKGROUND: This study examined the immediate outcomes during the perioperative period associated with drains in the setting of total shoulder arthroplasty or reverse shoulder arthroplasty. We hypothesized that drain use would result in lower postoperative hemoglobin and hematocrit levels that would increase transfusion rates and longer hospital stays that would increase hospital costs. METHODS: The study prospectively randomized 100 patients (55% women; average age, 69.3 years) who underwent total shoulder arthroplasty or reverse shoulder arthroplasty to receive a closed-suction drainage device (drain group, n = 50) or not (control group, n = 50) at the time of wound closure. Basic demographic information and intraoperative and postoperative data were collected. RESULTS: The groups were similar with respect to basic patient demographics. Postoperatively, drains had no effect on transfusion rates or any perioperative complication (P > .715). There were also no significant differences in hemoglobin or hematocrit levels immediately after surgery or on postoperative day 1. On average, patients were discharged from the hospital 1.6 days and 2.1 days postoperatively in the control and drain groups, respectively (P = .124). The average cost associated for the control cohort's hospital stay was $35,796 ± $13,078 compared with $43,219 ± $24,679 for the drain cohort (P = .063). DISCUSSION: Drain use after shoulder arthroplasty had no appreciable difference on short-term perioperative outcomes, postoperative anemia, length of hospital stay, or cost. It is possible that the potential negative effects of postoperative drainage are blunted by the routine use of tranexamic acid.

Valgus Extension Overload in Baseball Players.

Repetitive throwing, such as in baseball pitching, applies massive stress on the elbow. This can often lead to a predictable constellation of elbow injuries, such as valgus extension overload syndrome (VEO). The following review of VEO provides an understanding of relevant anatomy, explanation of pathomechanics, key aspects to clinical evaluation, effective treatment options, and indications for surgery. In addition, we provide the senior author's (CSA) preferred arthroscopic technique for cases of VEO refractory to conservative management.

Subacromial volume and rotator cuff tears: Does an association exist?

BACKGROUND: Rotator cuff pathology occurs commonly and its cause is likely multifocal in origin. The development and progression of rotator cuff injury, especially in relation to extrinsic shoulder compression, remain unclear. Traditionally, certain acromial morphologies have been thought to contribute to rotator cuff injury by physically decreasing the subacromial space. The relationship between subacromial space volume and rotator cuff tears (RCT) has, however, never been experimentally confirmed. In this study, we retrospectively compared a control patient population to patients with partial or complete RCTs in an attempt to quantify the relationship between subacromial volume and tear type. MATERIALS AND METHODS: We retrospectively identified a total of 46 eligible patients who each had shoulder magnetic resonance imaging (MRI) performed from January to December of 2008. These patients were stratified into control, partial RCT, and full-thickness RCT groups. Subacromial volume was estimated for each patient by averaging five sequential MRI measurements of subacromial cross-sectional areas. These volumes were compared between control and experimental groups using the Student's t-test. RESULTS: With the numbers available, there was no statistically significant difference in subacromial volume measured between: the control group and patients diagnosed partial RCT (P > 0.339), the control group and patients with complete RCTs (P > 0.431). CONCLUSION: We conclude that subacromial volumes cannot be reliably used to predict RCT type.

Surgical anatomy of the lower trapezius tendon transfer.

BACKGROUND: The precise surgical anatomy of the lower trapezius tendon transfer has not been well described. A precise anatomic description of the different trapezius segments and the associated neurovascular structures is crucial for operative planning and execution. We aimed (1) to establish a reliable demarcation between the middle and lower trapezius, (2) to establish the precise relationship of the main neurovascular pedicle to the muscle belly, and (3) to evaluate the utility of the relationships established in (1) and (2) by using the results of this study to perform cadaveric lower trapezius tendon harvest. METHODS: In phase 1, a single surgeon performed all measurements using 10 cadavers. In phase 2, 10 cadaveric shoulders were used to harvest the tendon by using the relationships established in phase 1. RESULTS: We found anatomically distinct insertion sites for the lower and middle trapezius. The lower trapezius inserted at the scapular spine dorsum and the middle trapezius inserted broadly along the superior surface of the scapular spine. The distance from tip of tendon insertion to the nearest nerve at the most superior portion of the lower trapezius was 58 mm (standard deviation ± 18). By use of these relationships, there were no cases of neurovascular injury during our cadaveric tendon harvests. CONCLUSION: The lower trapezius can be reliably and consistently identified without violating fibers of the middle trapezius. Muscle splitting can be performed safely without encountering the spinal accessory nerve (approximately 2 cm medial to the medial scapular border).

3.0-Tesla MRI and arthroscopy for assessment of knee articular cartilage lesions.

The purpose of this study was to evaluate the ability of 3.0-Tesla magnetic resonance imaging (MRI) to accurately assess knee articular cartilage lesions. Sixteen patients who had knee 3.0-T MRI and underwent knee arthroscopy for partial meniscectomy were included. Three fellowship-trained sports medicine orthopedic surgeons reviewed all images. Articular lesions on MRI were graded from I to IV and compared with arthroscopic grading using the Outerbridge and the International Cartilage Repair Society (ICRS) classifications. The articular surface was divided into 6 regions. Based on MRI findings, of the 288 articular surface evaluations, 113 (39%) surface evaluations were classified as disease-positive (grade 2 to 4). Kappa interrater reliability scores for MRI evaluation, Outerbridge classification, and ICRS classification were 0.13, 0.54, and 0.41, respectively. Using the Outerbridge classification as a reference standard, the sensitivity, specificity, and accuracy were 57%, 71%, and 63%, respectively. Using the ICRS classification, sensitivity, specificity, and accuracy were 59%, 71%, and 69%, respectively. When isolating the articular grading to the senior author on MRI evaluation vs Outerbridge classification, the sensitivity, specificity, and accuracy were 54%, 92%, and 75%, respectively. Based on the current findings, 3.0-T MRI is as an invaluable noninvasive tool with good diagnostic value for assessing articular cartilage lesions of the knee, although it may not be as sensitive and accurate as previously reported.