Telehealth Visits After Shoulder Surgery: Higher Patient Satisfaction and Lower Costs.

INTRODUCTION: Studies comparing the cost of in-person and virtual care are lacking. The goal of this study was threefold (1) to compare the cost of telemedicine visits with in-person clinic visits after common shoulder surgeries, (2) to measure the safety, and (3) to evaluate patient experience with telemedicine visits. METHODS: The In-Person Visit cohort (N = 25) and the telemedicine cohort (Virtual Visit cohort, N = 24) were selected from patients undergoing routine follow-up of common shoulder procedures. Time-driven activity-based costing was used to determine costs associated with each episode of care. Patient complications, satisfaction, convenience, and technical difficulties associated with telehealth were recorded. RESULTS: The average Virtual Visit was 54.1% less costly and 87.8% shorter than the In-Person Visit ($49 versus $107 per patient, 8.6 versus 70.1 minutes per patient, P < 0.01, respectively). One complication was missed in the Virtual Visit cohort, later captured by an in-person visit. All patients in the Virtual Visit cohort reported that the virtual visit was safe and convenient and showed high levels of satisfaction. DISCUSSION: Virtual visits for postoperative care of patients undergoing shoulder surgery are associated with decreased costs and high ratings of convenience and satisfaction. Postoperative complications may be more challenging to diagnose virtually.

Surgical time and outcomes of stemmed versus stemless total shoulder arthroplasty.

BACKGROUND: Stemless total shoulder arthroplasty (TSA) was approved for use in the United States in 2015, and there remains a paucity of data on its performance in this market. Decreased operative time without compromise of clinical outcomes is a theoretical advantage of stemless TSA, but no studies have evaluated this in a comparative study to date. Herein, the operative times and clinical outcomes of stemless vs. conventional stemmed TSA are investigated. METHODS: This is a retrospective cohort study, evaluating all consecutive TSAs performed by a single surgeon between 2015 and 2018. Data were collected from 59 patients who underwent TSA with conventional, stemmed humeral implants and 115 patients in whom a stemless humeral implant was used. Operative times and demographic data were collected retrospectively from the anesthesia record, and prospectively collected patient-reported outcome measures were collected from the Surgical Outcomes System database. For patient-reported outcome measure, visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores were recorded serially until a minimum 2-year follow-up. RESULTS: The average operative time was 24 minutes less in the stemless cohort compared with the stemmed cohort (104 minutes vs. 128 minutes, P < .001). Cost analysis showed a decreased personnel cost of 15.9% that correlates to a 3.1% overall reduction in operating room-associated cost. Patient-reported outcome scores significantly improved postoperatively in both cohorts across all time points. There was no difference found in visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores between the cohorts at the 2-year follow-up. CONCLUSIONS: Stemless TSA significantly reduces operative time with equivalent functional outcomes at a minimum 2-year follow-up.

Prevalence, management, and outcomes of nerve injury after shoulder arthroplasty: a case-control study and review of the literature.

Background: Neurologic injury is a rare and potentially devastating complication of shoulder arthroplasty. Patients typically present with a mixed plexopathy or mononeuropathy, most commonly affecting the axillary and radial nerves. Given the paucity of studies available on the topic, our goal was to elucidate the prevalence of nerve injury after shoulder arthroplasty and to describe the treatment course and outcomes of neurologic injuries. Methods: This is a retrospective case-control study performed at a single, urban, academic institution. Consecutive patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) by a single surgeon from 2014 to 2020 were reviewed, and patients with a documented nerve injury were identified. A control group of patients without nerve injury were selected in a 2:1 ratio controlling for age and procedure type (TSA vs. RSA; primary vs. revision). Data collected included demographics, comorbidities as per the Charlson Comorbidity Index, radiographic evaluations, surgical and implant details, patient-reported outcome measures, and perioperative complications. Results: Of 923 patients, 33 (3.6%) sustained an iatrogenic nerve injury: 10 (2.1%) after TSA, 23 (5.0%) after RSA, and 3 (7.8%) after revision arthroplasty. Axillary mononeuropathy was most common (42%), followed by brachial plexopathies (18%). There was no significant difference in age, sex, race, body mass index, and preoperative diagnoses between groups. Patients with nerve injury had fewer comorbidities (Charlson Comorbidity Index <3, 33 vs. 65%, P<.001). Patients with nerve injury had higher rates of cervical spine pathology (15 vs. 6%; P = .15) and increased postoperative lateralization (8.9 mm [7.2] vs. 5.5 mm [7.3]; P<.06). The majority (91%) were managed with observation alone. Three (9%) underwent an additional procedure: carpal tunnel release (1, 3%), ulnar nerve decompression (1, 3%), and ulnar nerve transposition (1, 3%) for peripheral compressive neuropathies. At the final follow-up, 19 (57%) nerves fully recovered, and 14 (43%) showed mild residual sensorimotor dysfunction. The mean time to first sign of recovery and ultimate recovery were 11 (7.2) and 36 (23.5) weeks, respectively. At the final follow-up, patients with nerve injury performed worse on patient-reported outcomes, including visual analog score pain (2.2 vs. 1.0, P<.001), American Shoulder and Elbow Surgeons score (67.8 vs. 84.8, P<.001), and Single Assessment Numeric Evaluation scores (62 vs. 77, P = .009). Discussion: Nerve injury after shoulder arthroplasty is rare, occurring in 3.6% of our patient population. Axillary mononeuropathy and brachial plexopathies are the most common. Most patients can be managed expectantly with observation and will recover at least partial nerve function, although clinical outcomes remain inferior to those without nerve complication.

Speed of recovery of the most commonly performed shoulder surgeries.

BACKGROUND: Shoulder surgery results in several months of rehabilitation, which is often underestimated by patients preoperatively. Currently, there is little written about this process of recovery. Information on this would help patients to anticipate the trajectory of their recovery. This would also provide a reference point allowing surgeons to compare a patient's progress in their recovery. The purpose of our study was to analyze and document the expected rate of recovery for the most common shoulder operations. METHODS: A retrospective analysis of all patients who underwent total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), arthroscopic rotator cuff repair (ARCR), and arthroscopic biceps tenodesis (BT) using prospectively collected data from the Surgical Outcomes System registry was performed. All patients included had a complete 2-year follow-up data set. The pain score (visual analog scale) was measured preoperatively at 2, 6, and 12 weeks and 6, 12, and 24 months. The American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) score were recorded preoperatively and after 6, 12, and 24 months. The speed of recovery, defined as the percentage of total improvement, for each procedure was assessed as the primary outcome parameter at all time points. RESULTS: All shoulder interventions resulted in significant improvement of the pain, SANE, and ASES scores 2 years after shoulder surgery. The speed of recovery of all 3 scores was highest after TSA at all measured time points and slowest after ARCR and BT. Measured by the pain score, 90% and 82% of the total improvement after TSA and RTSA was completed after 6 weeks compared to 58% and 59% after ARCR and BT, respectively. Six months postoperatively the ASES recovery rate was significantly higher after arthroplasty (TSA 96% and RTSA 85%) compared to ARCR and BT (76% and 77%, respectively). The SANE score recovery rate was between 82% and 92% (TSA 92%, RTSA 89%, ARCR 87%, BT 82%) 6 months after surgery. After 1 year all patient groups reached 89% or more of the total improvement in all scores, except for the pain after ARCR (89%). CONCLUSION: The improvement in pain is fastest after TSA and slowest after ARCR and BT. After TSA and RTSA, >80% of the total pain reduction is achieved 6 weeks postoperatively, whereas after ARCR and BT, >80% of the pain reduction is achieved only 6 months postoperatively. At 12 months postoperatively, the differences in recovery curves were not significant.

Does computerized CT-based 3D planning of the humeral head cut help to restore the anatomy of the proximal humerus after stemless total shoulder arthroplasty?

BACKGROUND: Restoration of proximal humeral anatomy (RPHA) after total shoulder arthroplasty (TSA) has been shown to result in better clinical outcomes than is the case in nonanatomic humeral reconstruction. Preoperative virtual planning has mainly focused on glenoid component placement. Such planning also has the potential to improve anatomic positioning of the humeral head by more accurately guiding the humeral head cut and aid in the selection of anatomic humeral component sizing. It was hypothesized that the use of preoperative 3-dimensional (3D) planning helps to reliably achieve RPHA after stemless TSA. METHODS: One hundred consecutive stemless TSA (67 males, 51 right shoulder, mean age of 62 ±9.4 years) were radiographically assessed using pre- and postoperative standardized anteroposterior radiographs. The RPHA was measured with the so-called circle method described by Youderian et al. We measured deviation from the premorbid center of rotation (COR), and more than 3 mm was considered as minimal clinically important difference. Additionally, pre- and postoperative humeral head diameter (HHD), head-neck angle (HNA), and humeral head height (HHH) were measured to assess additional geometrical risk factors for poor RPHA. RESULTS: The mean distance from of the premorbid to the implanted head COR was 4.3 ± 3.1 mm. Thirty-five shoulders (35%) showed a deviation of less than 3 mm (mean 1.9 ±1.1) and 65 shoulders (65%) a deviation of ≥3 mm (mean 8.0 ± 3.7). Overstuffing was the main reason for poor RPHA (88%). The level of the humeral head cut was responsible for overstuffing in 46 of the 57 overstuffed cases. The preoperative HHD, HHH, and HNA were significantly larger, higher, and more in valgus angulation in the group with accurate RPHA compared with the group with poor RPHA (HHD of 61.1 mm ± 4.4 vs. 55.9 ± 6.6, P < .001; HHH 8.6±2.2 vs. 7.6±2.6, P = .026; and varus angulation of 134.7° ±6.4° vs. 131.0° ±7.91, P = .010). CONCLUSION: Restoration of proximal humeral anatomy after stemless TSA using computed tomography (CT)-based 3D planning was not precise. A poorly performed humeral head cut was the main reason for overstuffing, which was seen in 88% of the cases with inaccurate RPHA. Preoperative small HHD, low HHH, and varus-angulated HNA are risk factors for poor RPHA after stemless TSA.